IRLF 


PSYCHOLOGY 

AND 

€NTAL_D[S€AS€ 
C.B.BURR.M.D. 


THE  LIBRARY 

OF 

THE  UNIVERSITY 
OF  CALIFORNIA  . 

Biology  Library 

GIFT  OF 

Franklin  P.   Nutting 


A  HANDBOOK 

OF 


Psychology  and  Mental 
Disease 


FOR  USE  IN  TRAINING-SCHOOLS  FOR  ATTENDANTS 

AND  NURSES  AND  IN  MEDICAL  CLASSES, 

AND  AS  A  READY  REFERENCE  FOR 

THE  PRACTITIONER 


BY 

C.  B.  BURR,  M.D. 

Medical  Director  of  Oak  Grove  Hospital  (Flint,  Mich.)  for  Mental  and  Nervous  Dis- 
eases; Formerly  Medical  Superintendent  of  the  Eastern  Michigan  Asylum; 
Member  of  the  American  Medico-Psychological  Association,  of  the 
American  Medical  Association,  of  the  American  Neurological 
Association,  of  the  Detroit  Society  of  Neurology  and 
Psychiatry;  Corresponding  Fellow  of  the  Detroit 
Academy  of  Medicine;  Foreign  Associate 
Member  of  Societe  Medico-Psy- 
chologique  of  Paris,  etc. 


FOURTH  EDITION       REVISED  AND  ENLARGED 
WITH   ILLUSTRATIONS 


PHILADELPHIA 

F.  A.  DAVIS  COMPANY,  PUBLISHERS 

ENGLISH  DEPOT: 

STANLEY  PHILLIPS,  LONDON 

1916 


COPYRIGHT,  1898,  THE  F..'A.  DAVIS  COMPANY 
COPYRIGHT,  1906,  F,  A.  DAVIS  COMPANY 
COPYRIGHT,  1914,  F.  A.  DAVIS  COMPANY 


Copyright,  Great  Britain.  All  Rights  Reserved 


Philadelphia,  Pa.,  U.  S.  A. 

Press  of  F.  A.  Davis  Company 

1914-1916  Cherry  Street 


Add  to.  Lib 

^ 

Girt 


/       \ 

)  01  O  4  U 

CM 

Q 


IT  is  a  source  of  much  gratification  to  the  author  that 
the  hope  expressed  in  the  preface  to  the  third  edition 
has  been  realized :  namely,  that  this  book  might  become 
increasingly  useful  to  medical  students  as  well  as 
nurses.  The  present  revision  concerns  itself  largely 
with  those  portions  of  especial  interest  to  medical  men. 

The  book  has  been  very  materially  enlarged.  There 
will  be  found  a  new  section  entitled  "Symbolism  in 
Sanity  and  in  Insanity."  Studies  have  been  made  of 
certain  paranoid  and  hysterical  states  on  the  basis  of 
Freud's  researches  and  a  more  detailed  description  of 
symptoms  and  symptom  groups  incorporated.  The 
section  on  "Management  of  Cases  of  Insanity  from 
the  Medical  Standpoint"  has  been  amplified  and,  it  is 
hoped,  improved. 

C.  B.  B. 

Oak  Grove  Hospital, 
Flint,  Michigan 


PREFACE  TO  FOURTH  EDITION. 


438 


CONTENTS. 


PART  I.    PSYCHOLOGY. 

PAGE 

Psychology 1 

Life;  the, Brain;  the  Mind;  Faculties  of  Mind. 
Thinking   12 

Development  of  the  Mind;  the  Senses;  Sensa- 
tion; Perception;  Memory;  Ideation,  Reasoning; 
Judgment. 

The  Localization  of  Function  in  the  Brain  24 

Feeling :    Emotion  28 

Volition   32 

General   Considerations    37 

Sensation;  Perception;  Hallucinations;  Illusions; 
Delusions;  Witchcraft;  Ideation;  Memory; 
Higher  Reflexes;  Volition;  Concept  Associa- 
tion; Inattentiveness ;  Incoherence;  Flight  of 
Ideas;  Verbigeration ;  Stereotypy;  Pressure  of 
Activity;  Retardation;  Opposition;  Negativism. 


PART  II. 

Symbolism  in  Sanity  and  in  Insanity  51 

Word  Association  and  Obsession. 


PART  III.    INSANITY. 

Insanity 62 

Definition. 

(v) 


vi  CONTENTS. 

PAGE 

Causes    63 

Direct  Physical;  Indirect  Physical  and  Emo- 
tional; Vicious  Habits;  Constitutional  and 
Evolutional. 

Forms  of  Insanity  67 

Infection  Psychoses 70 

Fever   Delirium    70 

Infection  Delirium  71 

Postf ebrile    Conditions    72 

Simple  Neuritis 73 

Treatment    73 

Exhaustion  Psychoses 74 

Collapse  Delirium    74 

'  Acute  Confusional  Insanity 76 

Chronic  Nervous  Exhaustion  (Neurasthenia)   . .  78 

Intoxication  Psychoses 82 

Lead  Poisoning 82 

Alcoholic  Intoxication   82 

Delirium  Tremens 82 

Dipsomania < 86 

Chronic   Alcoholism 87 

Alcoholic  Delusional  Insanity  87 

Alcoholic    Pseudoparesis : 88 

Alcoholic  Paranoia 91 

Alcoholic  Epilepsy 92 

Morphine  and  Opium  Addiction  92 

Cocaine  Habituation  98 

Insanities  from  Disturbance  of  Function  of  the  Thy- 
roid Gland , 99 

Myxedema    99 

Cretinism 99 

Hypo-  and  Hyper-  thyroidism    99 

Dementia  Prsecox 100 

Hebephrenic  Form 102 

Katatonic  Form   108 

Paranoid  Form 109 

Paralytic  Dementia  116 

Elated     Type;     Depressed     Type;     Differential 
Diagnosis. 


CONTENTS.  vii 

PAGE 

Juvenile    Paresis    129 

Dementia  with   Paralysis    130 

Insanity  from  Syphilis    131 

Manic-depressive   Insanity    132 

Excited  Phase  132 

Depressed  Phase 136 

Alternating  Type  142 

The  Presenile  and  Senile  (Involutional)  Insanities..  147 

Epileptic  Insanity 151 

The  Hysterical  Insanities   152 

States  of  Obsession 156 

Dual  Personality 160 

Fugues  161 

Idiocy  and  Imbecility 165 

Paranoia    .  165 


PART  IV. 

Management   of    Cases   of   Insanity    from   the   Medical 
Standpoint 173 

Medical  Examiners ;  Diagnosis ;  Nursing  Atten- 
tion; Medicinal  Treatment;  Bed  Treatment; 
Enemata;  Hydrotherapy ;  Mechanical  Feeding; 
Othematoma;  Travel;  Hospital  Care. 


PART  V. 

Management   of    Cases   of    Insanity   from   the   Nursing 
Standpoint    199 

Qualifications  of  Nurse ;  Administration  of 
Food;  Administration  of  Medicine;  Nursing; 
Correction  of  Pernicious  Habits  and  Checking 
Morbid  Impulses;  Mechanical  Restraint;  Ethics. 


ILLUSTRATIONS. 


PAGE 

The  Brain  as  Seen  from  the  Right  Side  5 

Physiological  Lobes  of  the  Cerebrum  9 

Neurone 11 

Sensation 14 

Perception 15 

Concept    21 

Zones  and  Centers  of  Cerebrum 25 

Volition  35 

Stereotypy 47 

Handwriting  in  Paralytic  Dementia   121 


(viii) 


PART  I. 


PSYCHOLOGY. 

PSYCHOLOGY  :  the  Science  of  Mind. 

The  word  Psychology  is  derived  from  two  Greek 
words:  Psyche,  Soul,  Mind;  and  Logos,  Discourse. 

The  problems  of  the  mind  involve  those  of  BIOLOGY  : 
the  Science  of  Life  (Bios,  Life;  Logos,  Discourse); 
and  PHYSIOLOGY  :  the  Science  of  properties  and  func- 
tions of  Living  Beings  (Physis,  Nature;  and  Logos). 

LIFE  is  defined  as  "a  relation  or  combination  of  mat- 
ter and  force  in  which  peculiar  phenomena  (ap- 
pearances) take  place,  which  are:  (1)  motion  from 
inherent  power,  (2)  a  capacity  for  appropriating  nour- 
ishing material  (assimilation),  and  (3)  the  capability 
of  multiplication  or  reproduction  for  the  preservation 
of  species.  In  the  higher  forms  differentiation1  of 
structure  and  development  occurs ;  and,  in  the  highest, 
sensibility  (feeling),  intellection  (thought),  and  will 
(volition)."2 

That  which  distinguishes  the  living  from  the  not 
living  is  the  possession  of  the  three  qualities  or  attri- 
butes: Motion,  Nutrition,  and  Reproduction — as 
above  mentioned. 

The  locomotive  moves  from  the  force  exerted  by  ex- 
pansion of  water ;  the  automobile,  from  that  occasioned 


1  A  production  of  diversity  of  parts  by  a  process  of  evolu- 
tion or  development. 

2  The  late  Dr.  A.  B.  Palmer. 

CD 


2  PSYCHOLOGY. 

by  the  sudden  explosion  of  gases  by  means  of  an  elec- 
tric spark.  Inorganic  substances  change  their  positions 
from  force  exerted  upon  them  (as  the  rolling  of  a  stone 
from  an  earthquake  upheaval).  Heat  and  electricity 
are  so-called  modes  of  motion.  The  acid  and  the  alkali, 
coming  together  in  solution,  make  disturbance  in  the 
glass  (motion  from  chemical  action).  All  these  are 
illustrations  of  motion,  but  not  motion  from  inherent 
power. 

Stones  enlarge  by  additions  to  their  surfaces  (accre- 
tion), but  cannot  appropriate  (assimilate)  substances 
with  which  to  grow. 

Two  or  more  stones  may  be  produced  from  one  by 
a  process  of  breaking  or  disintegration.  They  have  no 
ability,  however,  to  reproduce  their  kind. 

Certain  plants,  on  the  .contrary,  demonstrably  have 
motion  from  inherent  power:  as  witness  the  sensitive 
plant,  which  closes  when  its  leaves  are  touched;  the 
morning-glory,  which  opens  and  closes  its  petals;  the 
ivy,  which  climbs  the  conductor-pipe  or  the  tree;  the 
insect-eating  plant,  which  closes  about  and  absorbs  the 
prey  which  alights  upon  it.  Plants  also  have  ability 
to  appropriate  nourishing  material.  This  is  absorbed 
from  the  soil,  .or  from  the  atmosphere,  or,  as  in  the 
case  of  the  insect-eating  plant,  as  above  shown.  Plants 
reproduce  their  kind  by  contact  of  the  male  and  fe- 
male elements.  Conclusion  (JUDGMENT)  :  Plants  pos- 
sess life. 

The  lowest  form  of  animal  life  is  that  of  the  amoeba. 
This  consists  of  a  simple  mass  of  albuminoid  matter, 
possessing  irritability  (rudimentary  sensation),  con- 
tractility (enabling  motion  from  inherent  power),  and 
the  power  of  segmentation  or  division,  through  which 


PSYCHOLOGY.  6 

it  reproduces  itself.  From  this  low  form  of  life  up  to 
man,  showing  the  highest  organization,  differentiation 
of  structure  occurs. 

The  lowest  form  of  animal  life  in  which  a  nervous 
apparatus  (and  this  very  rudimentary)  appears  is  the 
jelly-fish.  This  animal  possesses  a  muscular,  digestive, 
and  circulatory  system  sufficient  for  its  needs.  The 
oyster  has  imperfect  nervous,  muscular,  circulatory, 
respiratory,  and  reproductive  apparatus.  The  oyster 
has  a  bony  system,  its  skeleton  being  upon  the  outside 
and  constituting  its  shell.  In  the  reptile  and  fish  there 
is 'a  higher  development  of  the  bony,  muscular,  diges- 
tive, circulatory,  respiratory,  nervous,  and  reproductive 
systems,  with  special  adaptation  of  structure  to  the 
conditions  in  which  the  animal  exists. 

Special  senses  are  not  developed  in  the  lowest  animal 
organisms.  In  the  very  lowest  form,  as  the  amoeba, 
there  is  irritability;  in  higher,  common  sensation  (im- 
pressions of  pain).  As  the  scale  is  ascended,  the  tactile 
sense,  and  from  this  on,  other  senses,  as  vision,  hearing, 
etc.,  develop. 

That  portion  of  the  nervous  system  contained  within 
the  skull  and  called  the  encephalon,  or  brain,  has  the 
following  principal  divisions :  the  cerebrum,  the  largest 
mass,  consisting  of  two  lobes  or  hemispheres  connected 
by  a  bridge  of  white  substance ;  the  '  cerebellum,  a 
smaller  mass  situated  behind  and  below  the  cerebrum  ; 
the  pons  Varolii,  a  bridge  which  partially  surrounds 
the  legs  or  crura  of  the  cerebrum  and  assists  in  binding 
the  lobes  of  the  cerebellum  together,  and  the  medulla 
oblongata,  which  in  its  lower  portion  is  continuous  with 
the  spinal  cord.  Three  membranes,  the  dura  mater, 
arachnoid,  and  pia  mater,  envelop  the  brain,  the  pia 


4  PSYCHOLOGY. 

lying  closely  to  it  and  the  dura  directly  beneath  the 
skull.  The  other  principal  divisions  of  the  central  ner- 
vous system  outside  the  skull  are  the  spinal  cord  and 
the  great  sympathetic,  the  latter  consisting  of  a  chain 
of  so-called  ganglia,1  situated  on  either  side  of  the 
spinal  column  and  hereafter  alluded  to  under  the  head 
of  Emotion. 

In  the  higher  animals,  accompanying  certain  nervous 
manifestations,  there  appears  what  is  called  conscious- 
ness (mind).  Fishes  can  be  taught  to  come  at  the  ring- 
ing of  a  bell ;  perroquets  and  canaries  to  live  in  (stage) 
harmony  with  their  hereditary  enemy,  the  cat,  to  per- 
form acrobatic  feats,  propel  carriages,  fire  miniature 
guns,  engage  in  mimic  battle  and  simulate  death ;  lions 
and  leopards  to  perform  tricks  and  subordinate  savage 
instincts  to  the  will  of  man;  horses  and  pigs  to  indi- 
cate numbers;  dogs  to  present  an  entire  play,  taking 
the  parts  of  policeman,  fireman,  sentimental  lover,  busy 
housewife,  and  nurse  for  baby.  Dogs  often  display  a 
high  type  of  reasoning  and  judgment.  The  word  "in- 
stinct" employed  as  indicating  the  conduct-governing 
force  in  lower  animals,  formerly  much  in  use,  is  now 
nearly  discarded.  Habit  associations  and  inherited 
tendencies  (instinctive)  are  numerous  and  obvious  in 
these,  but  the  psychologist  no  longer  denies  even  to 
those  low  in  the  scale  of  intelligence  a  certain  degree 
of  ability  to  group  concepts  (reason)  and  to  form  judg- 
ments through  which  action  is  determined. 

In  the  highest  form  of  life  (mankind)  the  develop- 
ment of  the  brain  and  nervous  system  reaches  its 


1  A  ganglion  (plural,  ganglia)  is  a  nodular  mass  consisting 
of  an  aggregation  of  nerve  cells. 


PSYCHOLOGY.  D 

greatest  perfection,  and  manifestations  of  mind  are  of 
the  most  complex  character. 

The  BRAIN  is  the  organ  of  the  mind. 

The  cerebrum,  with  which  in  this  connection  we  are 
chiefly  concerned,  is  composed  of  white  and  gray 
matter.  The  white  matter  is  fibrous,  and  makes  up  its 
bulk.  The  gray  matter  contains  the  cell  elements,  and 


The  brain  as  seen  from  the  right  side.     (Mills,  "Nervous 
Diseases,"  J.  B.  L.  Co.) 

is  for  the  most  part  found  upon  its  surface,  although 
there  are  islands  of  this  substance  in  the  interior.  The 
cortex,  or  covering  of  gray  matter,  dips  down  into 
grooves  upon  the  surface  of  the  brain,  increasing  its 
superficial  area  very  considerably.  The  raised  or 
prominent  portions  of  the  brain  found  between  these 
grooves  are  called  convolutions,  and  upon  their  depth 


6  PSYCHOLOGY. 

and  perfection  of  development  mental  strength  largely 
depends.  In  lower  forms  of  life  and  in  primitive 
peoples  they  are  smaller  and  less  definitely  outlined 
than  in  the  higher  orders  of  mankind. 

Simplicity  in  the  structure  of  the  brain  indicates  low 
mental  development,  as  shown  in  idiots  and  imbeciles. 
As  complexity  in  structure  increases,  convolutions  grow 
deeper,  and  gray  matter  becomes  more  abundant,  men- 
tal operations  are  correspondingly  higher.  The  size  of 
the  head,  unless  it  exceeds  or  falls  far  below  certain 
limits,  is  not  indicative  of  the  degree  of  mental  develop- 
ment.1 

"No  mental  modification,"  says  James,  "ever  occurs 
which  is  not  accompanied  or  followed  by  a  bodily 
change,"  and  experiments  upon  the  lower  animals  and 
observations  in  disease  in  man  show  that  the  brain  is 
the  organ  of  thought.  Disturbance  of  its  structure  or 
function  interferes  with  the  play  of  emotion  and  the 
faculty  of  ideation.  Serious  and  long-continued  im- 
pairment of  its  nutrition  displays  itself  in  settled  per- 
versions of  thought  and  feeling.  Injury  resulting  in 
cerebral  concussion  may  cause  temporary  or  permanent 
suspension  of  intellection,  and  defects  in  cerebral  devel- 
opment are  accompanied  by  partial  or  complete  absence 
of  the  higher  psychical  processes.  A  child  is  born  into 
the  world  the  structure  of  whose  brain  is  anatomically 
deficient,  or  the  growth  of  which  is  impeded  by  me- 
chanical compression.  The  result  is  idiocy  or  imbecil- 
ity;  the  development  of  the  higher  intelligence,  of  judg- 
ment and  reasoning,  is  impossible.  "The  pursuance  of 


1  There  are  both  microcephalic    (small-brained)    and  mac- 
rocephalic  (large-brained  or  at  least  large-headed)  idiots. 


PSYCHOLOGY.  7 

future  ends  and  the  choice  of  means  for  their  attain- 
ment," which,  according  to  James,  are  "the  mark  and 
criterion  of  the  presence  of  mentality,"  are  absent. 

The  gray  matter  is  the  originating  and  emissive  por- 
tion of  the  brain,  the  white  matter  the  conducting  por- 
tion. Nervous  force  originates  in  the  gray  matter.  The 
nervous  system  is  comparable  roughly  to  an  electric  cir- 
cuit, with  its  battery  of  cells,  in  which  force  originates ; 
with  its  white  matter  of  insulated  wires,  by  which  the 
current  is  conveyed ;  and  with  relay  stations  or  substa- 
tions, the  gray  islands  at  the  base,  in  which  messages 
from  the  central  station  are  grouped  and  co-ordinated, 
and  in  which,  under  certain  conditions,  messages  from 
without,  carried  by  the  nerves  of  sensation  and  special 
sense,  are  responded  to  without  the  intervention  of  the 
main  office. 

That  the  Brain  is  the  organ  of  the  mind,  and  that  in 
the  Cerebrum  (the  large  brain)  reside  the  higher  men- 
tal faculties,  is  shown : — 

1.  By  experiments  on  the  lower  animals.  The  pigeon 
deprived  of  the  cerebrum  remains  apathetic  and  droop- 
ing. If  thrown  into  the  air,  contact  with  this  element 
produces,  through  what  is  known  as  reflex  action,  the 
muscular  movements  of  flying,  but  these  gradually  be- 
come feebler  until  the  bird  sinks  to  the  ground.  If 
food  is  placed  within  its  reach  it  is  not  voluntarily  ap- 
propriated. If  inserted  far  back  in  the  mouth,  food  is 
swallowed  through  reflex  action.  The  frog  deprived  of 
its  cerebrum  rights  itself  if  an  attempt  is  made  to  turn 
it  over.  If  pricked  or  prodded,  it  jumps,  but  is  quiet 
and  motionless  unless  disturbed  by  contact  with  some- 
thing. It  initiates  nothing.  The  behavior  of  animals 
thus  deprived  of  the  cerebrum  is  akin  to  that  of  human 


8  PSYCHOLOGY. 

beings  suffering  from  profound   dementia    (acquired 
mental  impairment). 

2.  By  disease  of  the  brain,  which  is  so  often  asso- 
ciated with  disturbance  of  the  mental  operations. 

3.  By  the  mental  deficiencies  which  exist  in  connec- 
tion with  lack  of  cerebral  development,  as  in  idiots  and 
imbeciles. 

A  definition  of  mind  is  impossible.  It  is  known  only 
through  its  operations.  I  am  conscious  of  my  mind 
from  evidence  within  (subjective).  I  am  conscious  of 
mind  in  others  because  they  act  in  obedience  to  out- 
ward, or  apparent,  circumstances  as  I  do  myself  under 
similar  conditions  (objective  evidence).  Their  so- 
called  "reaction  to  their  environment"  is  similar  to  my 
own. 

As  to  the  relation  between  mind  and  brain,  this  much, 
and  only  this  much,  is  definitely  known,  that  upon  the 
relative  integrity  of  the  latter,  the  natural  operations 
of  the  former  more  or  less  closely  depend.  As  to  what 
consciousness  is — that  subtle  something  through  which 
we  are  made  aware  of  ourselves,  of  our  environment, 
of  ouf  relations  to  society,  by  means  of  which  we  act 
and  think  and  feel  intelligently — we  are  on  no  better 
ground  of  knowledge  than  were  the  philosophers  of 
long  ago  who  knew  not  the  use  of  the  scalpel,  the  mi- 
croscope, and  the  staining  agent. 

The  prefrontal  lobes  of  the  brain  have  been  desig- 
nated the  "higher  psychical."  This  is  perhaps  objec- 
tionable, inasmuch  as  the  brain  in  its  entirety  is  the 
great  psychical  organ,  and  all  portions  of  it  in  some 
way  participate  in  the  thinking  processes;  but  it  has 
been  shown  by  investigations  upon  the  brains  of  lower 
animals  that,  as  a  result  of  destruction  of  portions  of 


PSYCHOLOGY.  m  9 

these  lobes,  inhibitory  control  and  capacity  for  close  at- 
tention and  intelligent  observation  are  impaired.  If 
they  are  destroyed  completely  there  arise  alterations  in 
the  personality  and  incapacity  to  form  serially  groups 
of  images  or  re-presentations. 

The  cortex,  or  gray  covering  of  the  brain,  is  largely 
composed  of  layers  of  nerve  cells  of  different  shape  and 
size  and  of  infinite  number.  Those  of  the  so-called 


Physiological  lobes  of  the  cerebrum,  lateral  aspect : 
S,  Sylvian  fissure;  C,  central  fissure  or  fissure  of 
Rolando;  Po,  parieto-occipital  fissure.  (Mills,  "Nerv- 
ous Diseases,"  J.  B.  L.  Co.) 

pyramidal  cell  layer  are  thought  to  be  chiefly  concerned 
with  the  psychical  functions  because  of  the  peculiarities 
of  their  distribution  and  their  numerical  diminution 
and  imperfection  in  the  brains  of  those  of  low  order  of 
mental  development,  as  idiots.  The  so-called  psychical 
neurone  is  of  tree-like  form,  the  body,  with  the  thicker 
portion  of  the  process  extending  from  it,  representing 
the  trunk,  and  the  tuft-like  expansion,  the  foliage.  The 


10  PSYCHOLOGY. 

neurone  also  has  a  body  with  nucleus1  and  nucleolus2 
and  a  system  of  fibers  passing  through  it  which  unite 
at  the  basal  end  into  the  axis  cylinder  or  axone,  through 
which  impulses  generated  within  the  cell-body  are  con- 
veyed outward. 

The  prolongation  from  the  cell,  called  the  axone,  is 
insulated  by  a  sheath  throughout  its  entire  extent. 
This  insulation  is  for  the  apparent  purpose  of  prevent- 
ing dissemination  of  impulses  along  the  fiber.  Berkley 
says  that  the  researches  of  Flechsig  have  shown  that 
at  the  time  of  birth  .the  human  infant  possesses  only  a 
narrow  region  bordering  on  a  fissure,  called  the  Rolan- 
dic,  which  contains  fibers  having  these  sheaths.  In  the 
first  month  two  other  small  areas  in  the  cortex  show 
beginning  insulation,  and  from  this  time  on,  as  intel- 
lectual activities  increase,  further  and  further  insula- 
tion of  fibers  shows  itself  in  other  areas.  He  also  says 
that  in  the  earliest  stages  of  brain  growth  when  the 
nerve  cells  have  reached  nearly  their  adult  proportions, 
Flechsig  finds  only  four  centers  that  show  signs  of  a 
tendency  toward  individual  insulation  of  the  nerve 
fibers  of  the  cortex.  The  principal  fibrous  prolongation 
after  leaving  the  cell  body  throws  off  collateral 
branches.  Through  these  collaterals  association  con- 
tacts in  the  brain  are  established,  and  upon  the  perfec- 
tion of  their  development  and  the  multiplicity  of  their 
connections  with  other  cells  the  faculties  of  discriminat- 
ing judgment  and  of  comparison  of  impressions  with 
other  impressions  are  supposed  by  some  to  depend. 

Association  paths  between  the  different  areas  of  the 


1  A  center  of  growth — a  kernel. 

2  A  body  within  the  nucleus. 


PSYCHOLOGY. 


11 


Illustration  of  the  neurone.  A,  axone  with  col- 
laterals; B,  apical  dendrite,  showing  gemmules;  C, 
lateral  dendrites;  D,  cell-body.  (With  grateful 
acknowledgment  to  J.  F.  Burkholder,  M.D.,  Chicago.) 


12  PSYCHOLOGY. 

same  hemisphere  and  between  the  two  hemispheres  by 
the  bridge  called  corpus  callosum  are  more  numerous 
and  intricate  as  mental  development  increases.  Micro- 
scopical anatomy  demonstrates  that  up  to  maturity 
there  is  a  steady  increase  in  means  of  association  be- 
tween cells  of  the  cortex.  Each  cell  with  its  processes 
is  separate  and  distinct  from  its  fellows.  It  exists  as 
an  individual  unit  anatomically,  and  is  independent  of 
the  myriads  of  others  in  the  nervous  system.  Contact 
is  not  made  directly  between  the  prolongations  of  one 
cell  and  the  tufts  of  others,  but  an  interval  exists,  and 
upon  the  theory  of  failure  of  contact  or  delayed  con- 
tact has  been  built  up  the  retraction  theory  of  psychical 
cell  association.  It  has  been  assumed  that  in  the  rapid 
flow  of  ideation,  this  contact  is  continuous  and  exact, 
discontinuance  or  break  resulting  when  the  particular 
association  in  thought  is  no  longer  required  or  when 
the  flow  of  ideation  is  arrested  by  fatigue  or  changed 
conditions.  Thus  the  inability  to  recall  a  name  or  an 
incident  may  be*  due  to  the  failure  of  contact  between 
the  different  nerve-cell  elements  concerned  in  the  asso- 
ciation which  would  in  normal  conditions  arouse  the 
memory. 

The  faculties  of  mind  are  three  :— 

1.  THINKING  (intellection,  thought). 

2.  FEELING  (sensibility,  emotion). 

3.  ACTING  (will,  volition). 

Thinking. 

Development  of  the  Mind. — Knowledge  is  derived 
through  the  medium  of  the  SPECIAL  SENSES  and  mental 
development  depends  upon  the  reception  of  impressions 


PSYCHOLOGY.  13 

from  without  and  their  comparison  with  those  already 
stored  in  memory.  These  SPECIAL  SENSES  are  six  in 
number : —  . 

1.  Hearing:    mental  impressions  through  the  audi- 
tory apparatus. 

2.  Seeing:  mental  impressions  through  the  visual  ap- 
paratus. 

3.  Smelling:  mental  impressions  through  nerves  sup- 
plied to  the  nasal  mucous  membrane. 

4.  Tasting:  mental  impressions  through  nerves  sup- 
plied to  the  tongue. 

•  5.  Touch:  mental  impressions  through  sensory 
nerves  supplied  to  external  parts  of  the  body,  skin,  and 
mucous  membranes. 

6.  Muscular:  mental  impressions  as  to  force  and  re- 
sistance derived  from  contracting  muscles.1 

There  are  necessary  to  the  mental  upbuilding : — 

1.  SENSATION. 

2.  PERCEPTION. 

3.  MEMORY. 

4.  IDEATION. 

5.  REASONING. 

6.  JUDGMENT. 

A  SENSATION  is  an  impression  made  upon  an  organ 
of  sense,  which  organ  must  be  composed  of  three 
parts  :— 

1.  A  nervous  mechanism  to  receive  the  impression. 

2.  A  sensory  nerve,  or  nerve  of  special  sense,  to  con- 
vey the  impression  to  the  brain. 


1  Compare  the  impression  received  from  compressing  a 
rubber  ball  with  that  from  a  similar  attempt  upon  a  piece  of 
steel.  The  essential  difference  between  the  touch  and  the 
muscular  sense  is  plainly  apparent. 


14  PSYCHOLOGY. 

3.  A  nerve  cell,  or  group  of  cells,  to  receive  the  im- 
pression. 

Take  the  eye  for  illustration.  A  ray  of  light  from 
some  object  falls  upon  the  retina.  An  impression  is 
conveyed  through  the  optic  nerve  to  the  center  of  sight 
in  the  brain  and  there  received.  This  is  a  simple  sen- 
sation. SIGHT,  or  SEEING,  is  a  different  thing,  how- 
ever, and  involves,  just  as  hearing,  smelling,  touch, 
taste,  and  the  muscular  senses  do,  something  else,  which 
is  called 


^Hk-r- — ~ 

Illustration  of  simple  sensation  of  touch.  Arrow 
represents  impression  conveyed  by  sensory  nerve  to 
nerve-center  in  brain. 

PERCEPTION.  This  is  at  the  very  foundation  of 
thought  and  is  the  conscious  recognition  of  the  external 
causes  of  sensation. 

To  illustrate:  nothing  is  so  helpless  as  the  human 
infant  at  birth.  Unlike  the  chick,  which  as  soon  as  it 
emerges  from  the  shell  helps  itself  to  food  placed  in 
the  incubator,  the  child  is  utterly  dependent  and  with- 
out means  for  self-preservation  or  protection.  It  is  an 
unorganized  bundle  of  tissues  and  passes  during  the 


PSYCHOLOGY.  15 

early  weeks  of  life  a  purely  vegetative  existence."  At 
three  months  of  age  or  thereabouts  the  child  is  said  to 
"notice" — that  is  to  say,  it  takes  cognizance  of  what 
comes  before  it.  It  follows  with  the  eyes  a  candle  or  a 
ball  of  bright  yarn,  watches  for  them  and  associates 
pleasant  sensations  with  them.  It  perceives  that  the 
candle  or  the  ball  of  yarn  is  the  cause  of  an  agreeable 
feeling.  This,  the  conscious  recognition  of  the  cause, 
is  Perception.  When  first  a  nursing-bottle  is  placed  to 
its  lips,  these  close  down  about  the  nipple  and  the  opera- 


Illustration  of  visual  perception. 

tion  of  sucking  begins.  There  is  an  impression  conveyed 
by  the  touch  and  taste  organs  of  the  mouth,, through 
corresponding  nerves,  to  the  sensory,  or  special  sense, 
centers  in  the  brain ;  from  these  centers  reflected  upon 
motor  nerve-centers  in  the  brain,  and  through  motor 
nerves  going  from  the  brain  to  the  muscles.  Result: 
the  operation  of  sucking,  which  is  at  first  a  purely  re- 
flex act.  Later,  the  child  watches  for  the  bottle  of 
milk,  extracts  its  contents  when  offered,  or  helps  itself 
if  the  bottle  is  placed  in  the  cradle.  There  is  here 
Perception:  the  recognition  of  the  external  causes  of 
the  sensations  which  the  bottle  and  its  contents  furnish. 
There  are  necessary  to  Perception : — 


16  PSYCHOLOGY. 

1.*  A  nervous  mechanism  to  receive  impressions. 

2.  Sensory  nerves,  or  nerves  of  special  sense,  to  con- 
vey impressions. 

3.  Nerve-centers  in  the  brain  to  receive  impressions. 

4.  Consciousness. 

Perception  is  made  up  from  a  number  of  distinct  per- 
cepts; as,  for  example,  form,  size,  color,  vibration, 
density,  taste.  These  individual  impressions  united, 
and  with  the  aid  of  consciousness,  form  a  percept  of 
the  object. 

In  order  that  percepts  once  acquired  may  be  stored 
up  for  future  use,  there  is  necessary  another  mental 
faculty,  which  is 

MEMORY.  This  is  the  faculty  which  enables  the  re- 
tention and  reproduction  in  mind  of  impressions  re- 
ceived. 

Impressions  proceed  from  the  different  organs  of 
sense  to  areas  of  the  brain  in  which  they  are  registered. 
Memories  of  percepts  are  created.  Of  the  function, 
memory,  Scripture  writes  as  follows :  "If  I  were  writ- 
ing a  dictionary,  I  would  define  memory  as  that  portion 
of  mental  life  about  which  everybody  has  been  talking 
for  three  thousand  years  without  finding  out  anything 
more  than  anybody  of  common  sense  knows  before- 
hand." Bergson,  in  "An  Introduction  to  Metaphysics," 
makes  use  of  the  vivid  expression :  "I  notice  the  mem- 
ories which  more  or  less  adhere  to  these  perceptions 
and  interpret  them."  So  much  for  memory.  It  is 
known  only  through  its  manifestations. 

There  are  two  kinds  of  Memory: — 

1.  Memory  of  percepts. 

2.  Memory  of  self  (Organic  Memory). 


PSYCHOLOGY.  17 

The  memory  of  self  (organic  memory)  permits  the 
registration  and  storing  up  of  impressions  from  all 
parts  of  our  bodies :  from  the  skin,  bones,  muscles,  and 
internal  organs.  These  are  for  the  most  part  sensory 
memories  carried  originally  by  inward-conducting  (sen- 
sory) nerves.  There  are  also  motor  memories  origi- 
nally collected  from  muscles  influenced  to  action 
through  outward-moving  impulses  from  the  brain. 

Upon  this  memory-storing  the  Ego — the  Personality 
— depends.  Sensations  such  as  are  here  mentioned  do 
not,  as  a  rule,  come  into  consciousness  independently; 
but,  taken  together  in  health,  they  constitute  our  feel- 
ing of  well-being:  our  sense  of  self.  In  disease  we 
may  become,  at  times,  acutely  conscious  of  some  or  all 
of  them.  The  development  of  the  personality  is  ex- 
tremely interesting. 

The  child  at  first  is  unconscious  of  its  own  existence, 
of  its  own  individuality.  It  refers  to  itself  in  the  third 
person:  "J°hnme  wants  it,"  "Mamie  wants  it."  The 
Ego — I — is  not  present.  The  child  inspects  its  fingers 
and  toes,  as  it  does  that  which  is  held  before  it,  as 
something  foreign  to  itself.  Later,  organic  sensations 
proceeding  from  the  fingers  and  toes  and  impressing 
themselves  upon  the  consciousness  give  to  the  child  the 
recognition  of  proprietorship.  The  organs  become  part 
of  the  child's  body.  The  existence  of  the  child  at  first 
seems  to  be  of  a  dual  character.  Later,  the  Ego  is 
formed — the  personality — through  sensations  proceed- 
ing from  all  the  organs  and  tissues  of  the  body  and 
registered  in  the  organic  memory. 

The  PERSONALITY  is  of  great  interest  to  those  study- 
ing insanity,  for  in  disease  of  the  mind  it  is  frequently 
found  that  alteration  in  organic  sensations  has  given 


18  PSYCHOLOGY. 

to  the  individual  an  impression  of  bodily  loss  or  of 
change  in  constitution.  Change  in  sensation,  proceed- 
ing from  the  foot,  may  lead  to  the  belief  that  this  mem- 
ber is  lost  or  dead.  Change  in  nervous  action  and 
checking  or  hindrance  of  mental  operations  may  lead 
to  the  delusion  that  the  mind  is  under  the  control  of 
another.  Defective  elimination  from  torpor  of  the 
stomach  and  bowels,  causing  a  metallic  taste  in  the 
mouth,  may  occasion  the  belief  that  poison  has  been 
administered;  inadequacy  or  impotence  in  the  sexual 
sphere  arising  from  over-indulgence  or  indiscretions 
may  be  attributed  to  a  "charm"  or  hypnotic  influence 
exerted  by  another  who  has  given  real  or  fancied 
ground  for  jealousy.1  Change  in  the  action  of  the 
nerves  of  the  skin  may  occasion  the  belief  that  elec- 
tricity or  some  harmful  agency  is  at  work  upon  the 
body.  All  sensations,  indeed,  may  be  so  altered  in 
insanity  as  to  lead  to  the  belief  in  a  double  person- 
ality. 

This  is  not  difficult  to  understand  when  we  call  to 
mind  the  clod-like,  heavy,  foreign  feeling  of  a  frozen 
foot,  or  that  of  an  extremity  which  has  been  separated 
from  vascular  and  nervous  connection  with  the  trunk 
by  a  tightly  constricting  elastic  band.  Here  the  sensory 
nerves  are  blunted,  and  sensations  proceed  from  the 
tissues  above  the  affected  point.  The  organic  memory 
may  be  so  vivid  in  its  reproductions  as  to  convey  to  the 


1  Here  wise  discrimination  is  necessary  on  the  part  of  the 
examiner.  An  insane  delusion  is  no  less  a  delusion  because 
there  may  be  fundamentally  good  reason  for  criticism  or  dis- 
trust of  the  one  toward  whom  it  is  directed.  It  is  the  char- 
acter or  quality  of  the  belief — its  reasonableness — which  is 
significant. 


PSYCHOLOGY.  19 

soldier  the  consciousness  of  the  presence  of  an  ampu- 
tated extremity. 

IMPRESSIONS  taken  cognizance  of,  or  perceived  by, 
the  mind  are  hoarded  by  Memory. 

The  process  of  grouping  percepts  together  (Re-pres- 
entation— Re-collection)  by  the  aid  of  Memory,  to 
form  concepts  or  ideas,  is  called  IDEATION. 

Through  impressions  coming  into  consciousness, 
primitive  notions  of  size,  consistency,  odor,  taste,  etc., 
are  formed.  Grouped  together,  these  form  a  percept 
of  the  object  in  its  entirety,  and  these  primitive  percepts 
associated  by  the  aid  of  memory  form  concepts  or 
ideas. 

Illustration :  Take  an  object  in  the  hand ;  receive  all 
the  impressions  possible  from  it  through  the  medium 
of  common  sensation  and  the  special  senses.  There  is 
here  a  group  of  impressions  coming  into  consciousness, 
constituting  a  percept  of  the  object  (Presentation). 
Remove  the  object,  and  associate  the  different  indi- 
vidual percepts  together  through  the  aid  of  memory.  It 
may  still  be  seen,  or  heard,  or  felt.  Thus  is  constituted 
a  concept,  or  idea,  which  is  a  group  of  percepts  repro- 
duced in  memory  (Re-presentation — Re-collection). 

On  contact  with  the  flame  of  the  candle  the  child's 
finger  is  immediately  withdrawn.  This,  a  simple  reflex 
act,  is  carried  on  through  the  sensory  nerves,  the  con- 
ducting paths  of  the  cord,  the  ganglia  at  the  base  of  the 
brain,  and  the  motor  nerves.  With  this  first  experience 
of  the  candle,  however,  there  is  registered  in  perceptive 
centers  the  memory  of  disagreeable  sensation.  Next 
confronted  with  the  candle,  the  child  draws  back  in 
terror.  Associated  with  the  sensory  memory  are  others 
of  a  visual  character  which  enable  the  child  to  identify 


20  PSYCHOLOGY. 

the  candle  as  the  cause  of  the  previous  painful  experi- 
ence (Perception,  Ideation).  Later  on,  as  its  observa- 
tion increases,  there  is  a  tentative  investigation  and 
pleasurable  percepts  arise  from  the  proximity  of  the 
light,  Judgment  (the  higher  control)  having  meantime 
been  set  in  operation  to  restrain  the  child  from  putting 
its  hand  into  the  flame.  Later  come  the  concepts  con- 
nected with  the  use  of  the  candle,  and  from  this  time 
all  manner  of  association  of  concepts  and  judgments 
based  thereupon  may  arise.  In  the  first  instance  the 
simple  reflexes  were  involved.  In  the  second  there 
come  into  play  simple  associations  of  concepts,  and  in 
the  latter  the  higher  cerebral  functions  of  Reasoning 
and  Judgment. 

For  the  second  process,  the  visual  perceptive  centers 
in  the  posterior  brain  and  the  conceptual  centers  in  the 
midbrain  come  into  play;  for  the  third,  the  higher 
cerebration,  association  of  concepts  to  form  judgments, 
there  is  demanded,  in  addition  to  the  interaction  of  the 
different  portions  of  the  brain  already  alluded  to,  the 
action  of  the  forebrain,  or  the  so-called  prefrontal 
lobes. 

REASONING. — This  faculty  is  also  necessary  to  the 
development  of  the  mental  life.  Reasoning  is  the  asso- 
ciation of  concepts,  or  ideas,  to  form  a  judgment,  and 
the  association  of  judgments  to  form  new  judgments. 
In  reasoning,  we  weigh  and  compare  concepts,  or  ideas, 
by  their  likeness,  or  similarity,  and  by  their  unlikeness, 
or  dissimilarity. 

Passing  along  the  street  of  a  strange  city,  I  observe 
banners  waving,  bunting  and  floral  decorations  con- 
spicuously displayed.  The  faces  of  those  met  wear 
cheerful  expressions.  I  hear  lively  airs  played  by  dis- 


PSYCHOLOGY.  21 

tant  bands.  Association  of  these  concepts  by  the  aid 
of  memory  of  previous  experiences  permits  the  judg- 
ment that  a  fete  is  in  progress  or  about  to  begin. 

Dirge-like  music,  flags  at  half-staff,  the  booming  of 
guns,  the  tramp  of  marching  feet  call  up  the  judgment 
that  a  military  funeral  is  in  progress. 

A  loud-toned  bell  strikes  one — two,  one — two — 
three,  a  siren  whistle  peals  out,  there  is  a  rattling  of 
hoofs  on  the  pavement,  bells  clang,  and  a  rumble  of 


Illustration  of  concept,  or  idea.  Each  grape  rep- 
resents the  memory  of  a  percept.  These  united  by 
the  stem,  ideation,  form  the  concept. 

rapidly  moving  vehicles  is  heard.  There  is  a  sudden 
hush  in  other  traffic  on  the  street.  Those  sitting  near 
me  playing  cards  prick  up  their  ears  and  count  the 
strokes  of  the  bell,  then  turn  and  resume  their  play — 
all  save  one.  He  hurriedly  leaves  the  room.  Judg- 
ment: 1.  A  fire  is  in  progress.  2.  It  is  in  the  precinct 
in  which  the  one  resides  who  has  so  hurriedly  made 
his  exit. 

The   association   of   the   sound   of   the   deep-toned 
whistle   and  the   slowing  of   machinery   calls   up  the 


22  PSYCHOLOGY. 

judgment  that  a  fog  has  settled  down  and  instantly 
there  arises  the  fear  of  collision  unless  navigation  is 
carefully  conducted.  The  association  may  be  carried 
so  far  that  fear  and  trepidation  are  lost  in  speculation 
upon  the  size  and  shape  of  icebergs  and  the  probable 
loss  of  time  in  the  ship's  running  consequent  upon  the 
unexpected  incident.  Previous  concepts  connected 
with  the  ill-fated  Titanic  may  be  revived  and  a  whirl 
of  judgments  fully  or  fragmentarily  (according  to  the 
degree  of  expert  knowledge  one  possesses)  formed  as 
to  the  expediency  of  building  steamships  of  that  class, 
as  to  the  divorcement  of  practical  navigation  from 
business  management,  and  the  necessity  for  complete 
independence  of  the  ship's  captain  at  sea;  as  to  the 
practicability  of  larger  and  more  varied  life-saving 
equipment,  as  to  the  claims  of  the  weak  and  defense- 
less, and  as  to  the  toweringly  high  quality  of  American 
manhood  and  chivalry  displayed  without  exception  in 
this  shocking  disaster. 

Use  for  illustration,  the  naturalist's  classification  of 
the  animal  kingdom.  A  similarity  in  structure,  in  that 
all  possess  a  spinal  column,  causes  large  numbers  of 
animals  of  widely  different  appearance  to  be  grouped 
under  the  designation  vertebrates.  So  of  other  orders : 
essential  differences  in  structure  separate  the  mollusks 
from  the  articulates,  and  the  articulates  from  the 
radiates.  To  go  further,  closer  anatomical  or  physio- 
logical resemblances  cause  the  division  of  the  verte- 
brate kingdom  into  families,  or  subclasses:  mammals, 
birds,  reptiles,  and  fishes.  This  process  of  weighing, 
comparing,  and  measuring  is  called  Reasoning,  and  the 
result  of  the  process,  Judgment. 

Associate  concepts  of  compression  and  steam  (ex- 


PSYCHOLOGY.  23 

panded  water).  There  is  called  up  the  concept  of 
force,  and  a  container  of  metal  to  supply  resistance 
that  the  force  may  be  utilized.  Judgment :  Expanded 
water  confined  in  a  receptacle  of  steel — a  boiler — 
exerts  great  force,  and  may  be  used  in  moving  power- 
ful bodies  (locomotives). 

Again:  Compare  the  idea,  or  concept,  man — which 
involves  many  percepts  of  his  different  attributes — 
with  the  concept  reptile.  Judgment:  Man  is  the 
superior  being. 

Again :  One  looks  out-of-doors  upon  a  cloudy  sky. 
He  perceives  the  absence  of  sunlight  and  the  direction 
of  the  wind ;  is  conscious  of,  or  perceives,  a  chilliness. 
He  groups  these  percepts  together,  and  by  the  aid  of 
memory  reduces  them  to  concepts.  There  is  a  re-col- 
lection of  past  experiences.  He  associates  the  concepts 
together  by  reasoning.  Result :  Judgment,  that  the 
day  will  be  unpropitious  for  a  picnic. 

JUDGMENT  :  The  result  of  a  comparison  or  associa- 
tion of  concepts,  or  of  the  comparison  or  association  of 
judgments. 

Let  two  telegraph-poles  be  taken  as  representing 
each  a  concept,  or  idea.  Reasoning  is  the  wire  that 
unites  the  two ;  Judgment  is  the  result  of  the  union. 

Or  let  each  pole  represent  a  judgment.  The  wire, 
reasoning,  unites  the  two,  the  whole  forming  a  new 
judgment. 

To  recapitulate : — 

Sensation  -[-  Consciousness  =  Percept. 

Percept  -f-  Percept  +  Memory  =  Concept. 
Concept  +  Concept  =  Judgment, 

or 
Judgment  +  Judgment  =  New  Judgment. 


24  PSYCHOLOGY. 

The  plus  sign  which  stands  between  the  words  Per- 
cept and  Memory  is  the  equivalent  of  Ideation. 

The  plus  sign  which  stands  between  the  words  Con- 
cept and  the  words  Judgment  is  the  equivalent  of 
Reasoning. 

As  before  stated,  Sensation,  Perception,  Memory, 
Ideation,  Reasoning,  Judgment,  enter  into  the  thinking 
process.  If  any  avenue  to  the  brain  is  closed,  as  by 
congenital  deafness  or  blindness,  mental  development 
and  mental  ability  are  correspondingly  lessened,  al- 
though scientific  methods  applied  in  the  education  of 
the  remaining  senses  go  far  to  remedy  the  deficiency. 
The  experience  in  the  case  of  Helen  Keller,  congeni- 
tally  blind  and  deaf;  her  astonishing  mental  develop- 
ment, through  education  by  means  of  the  tactile  sense, 
constitutes  an  entire  book  of  Psychology. 

Thought  in  man  is  usually,  perhaps  invariably,  con- 
ducted in  words  or  their  visible  signs.  Let  anyone  try 
to  think  and  he  will  find  that  he  is  mentally  grouping 
words  together  into  sentences  and  that  his  unspoken 
idea  is  framed  as  if  it  were  to  be  expressed.  The 
•  deaf-mute,  who  has  not  a  vocabulary  of  words,  thinks 
in  visible  signs;  that  is,  in  gestures  which  stand  for 
the  representatives  of  ideas.1 

The  Localization  of  Function  in  the  Brain. 

The  study  of  cerebral  topography  has  made  rapid 
strides  during  the  last  quarter-century.  Since  1870,  at 
which  time  Hitzig  showed,  through  experiments  on 
the  brain  of  a  dog,  that  co-ordinated  movements  could 

1  See  footnote  on  page  39,  and  the  chapter  "Symbolism 
in  Sanity  and- in  Insanity,"  page  51. 


PSYCHOLOGY.  25 

be  produced  by  electric  irritation  of  certain  definite  re- 
gions of  the  cortex,  and  the  period,  a  trifle  later,  of 
Ferrier  and  Munk,  who,  through  irritation  and  excision 
of  the  cortex,  mapped  out  certain  regions  having  to  do 
with  definite  special  senses,  knowledge  of  the  subject 
has  been  steadily  increasing  and  is  becoming  more  and 
more  accurate.  This  knowledge  has  in  recent  years 


Zones  and  centers  of  the  lateral  aspect  of  the  human  cere- 
brum.    (Mills,  "Nervous  Diseases,"  J.  B.  L.  Co.) 

been  greatly  augmented  by  the  tremendous  advances 
made  in  cerebral  surgery  through  the  work  of  Horsley, 
of  England ;  Gushing,  of  America,  and  others.  The 
best-known  area  is  that  of  the  motor  region  of  the 
cortex.  Mechanical  irritation  of  different  parts  of  this 
motor  area  produces  co-ordinated  movements.  From 
this  region  motor  incitations  pass  out  to  centers  in  the 
medulla  and  cord,  and  are  discharged  upon  the 
muscles ;  and  pressure  or  structural  disease  in  a  given 


26  PSYCHOLOGY. 

locality  in  this  motor  area  produces  loss  of  power  in 
the  group  of  muscles  innervated  therefrom. 

In  other  areas  are  situated  the  psychical  centers  of 
vision,  hearing,  and  smell,  and  their  destruction  in- 
volves a  loss  of  memory  of  percepts  derived  through 
the  medium  of  these  special  organs.  In  mental  blind- 
ness there  is  a  lack  of  recognition  of  familiar  objects, 
and  there  may  be  such  failure  as  to  persons  with  whom 
one  has  been  on  intimate  terms.  There  are  all  degrees 
of  cortical,  visual  blindness — from  the  inability  to  com- 
prehend the  meaning  of  written  and  printed  words  to 
that  extreme  involvement  of  the  psychical  centers  al- 
ready mentioned.  The  occipital  lobe  and  the  adjoining 
area  of  the  parieto-temporal  lobe,  called  the  angular 
gyrus  or  convolution,  contain  this  visual  center. 

The  psychical  center  for  hearing  is  located  in  the 
first  and  second  temporal  convolutions.  Lower  down 
in  the  temporal  and  in  nearby  portions  of  the  brain  are 
presumably  located  the  centers  for  taste  and  smell.  One 
may  be  mentally  deaf  notwithstanding  the  fact  that 
the  organs  of  hearing  outside  the  brain  are  intact.  In 
a  general  way  the  sensory  part  of  the  brain  is  located 
posteriorly,  the  motor  portion  anteriorly.  In  the  latter 
portion  is  found  the  interesting  convolution  of  Broca 
in  which  are  located  the  memories  for  articulate  speech. 
Aphasia,  inability  to  remember  words  and  apply  them 
in  their  proper  relation,  may  be  total  or  partial.  The 
enunciation  of  a  considerable  number  of  words  or  sen- 
tences may  be  possible,  or  the  vocabulary  limited  to  a 
few,  as  "yes,"  "no,"  and  "you."  I  have  had  under  ob- 
servation a  patient  whose  sole  exclamation  is  a  sound 
like  "ein."  This  she  gave  forth  with  varying  inflec- 
tions and  her  manner  betrayed  disgust  or  reproachful- 


PSYCHOLOGY.  27 

ness  that  her  communications  were  not  correctly  inter- 
preted. She  apparently  understood  all  that  was  said, 
but  her  word-forming  power  was  nil.  In  this  case 
there  was  also  agraphia,  or  inability  to  express  thought 
in  written  characters.  These  two  conditions,  though 
not  necessarily,  are  commonly  associated.  One  may 
write  and  understand  written  or  printed  speech  when 
deprived  of  the  use  of  spoken  language. 

Aphasia  due  to  the  lack  of  word-forming  capacity 
or  the  loss  of  object-naming  power  is  not  to  be  con- 
founded with  the  inability  to  articulate  distinctly  and 
the  gradual  loss  of  speech  so  common  in  a  certain  form 
of  brain  disease,  paretic  dementia.  Here  the  involve- 
ment affects  the  motor  zone  in  its  entirety,  and  the 
resulting  impairment  is  that  of  ability  to  co-ordinate 
muscular  action — that  is  to  say,  to  work  muscles  to- 
gether. This  symptom  is  called  Ataxia.  Apraxia,  is 
another  symptom  sometimes  associated  with  aphasia. 
It  is  due  to  the  loss  of  recollection  of  the  uses  of  ob- 
jects. Handed  a  pencil,  the  patient  inserts  it  in  his 
mouth.  He  attempts  to  polish  his  shoes  with  a  Jews- 
harp  and  to  comb  his  hair  with  a  hammer. 

The  zone  of  language  is  said  to  comprise  three  cen- 
ters and  has  been  enlarged  by  certain  authors  to  in- 
clude a  conceptual  center.  Mills  says  of  the  zone  of 
language  that  it  includes  three  centers,  namely,  that 
for  the  images  of  articulation,  that  for  auditory  images, 
and  that  for  visual  images.  "Each  of  these  centers  is 
situated  in  the  part  of  the  zone  of  language  which  ap- 
proaches most  nearly  to  its  corresponding  general  zone, 
motor  or  sensory.  The  motor  center  of  articulation  is 
in  proximity  to  the  psychomotor  region,  the  center  of 
visual  images  approaches  most  nearly  the  general 


28  PSYCHOLOGY. 

visual  zone;  and  the  center  of  auditory  images  is  in 
close  relation  with  the  general  auditory  sphere.  In  this 
zone  of  language  the  center  for  auditory  images  is 
that  first  evolved  and  most  deeply  organized.  As  a 
rule,  the  child's  first  ideas  of  language  come  through 
hearing;  articulate  speech  is  next  evolved;  the  child 
hears,  and  it  speaks;  it  learns  to  repeat  the  names  of 
persons  and  objects  with  which  it  comes  into  relations ; 
later,  in  those  who  become  educated,  a  center  for  the 
visual  images  of  letters  and  words  is  organized,  and 
still  later,  at  least  according  to  some  authorities,  a 
center  for  graphic  motor  images.  The  auditory  and 
motor  speech  centers  continue  to  be  for  the  vast  major- 
ity of  people  most  important  constituents  of  the  zone 
of  language." 


Feeling :    Emotion. 

Were  logical  order  followed,  Feeling,  or  Emotion, 
the  second  manifestation  of  mind,  should  have  been 
considered  previous  to  thinking,  inasmuch  as  feeling 
(sensibility)  must  inevitably  precede  thinking.  The 
term  "feeling"  must  not  be  confounded  with  the  sen- 
sation springing  from  the  special  sense  of  touch.  What 
is  understood  by  "feeling,"  as  the  word  is  here  used, 
is  a  bundle  of  mental  experiences,  some  of  an  agree- 
able, others  of  a  disagreeable,  character.  The  major- 
ity of  concepts  are,  in  some  degree,  pleasurable  or 
painful — that  is,  there  are  few  which  may  be  classed 
as  entirely  neutral:  from  which  some  satisfaction,  or 
the  reverse,  is  not  derived.  To  the  extent  to  which 
ideas  are  accompanied  by  pleasurable  or  painful  feel- 
ings they  may  be  considered  emotional. 


PSYCHOLOGY.  29 

An  emotion,  therefore,  may  be  defined  as  an  idea 
accompanied  by  a  feeling  of  pleasure  or  pain.  As  the 
feeling  preponderates  the  idea  grows  less  and  less  dis- 
tinct until  almost  overshadowed.  The  word  "Emo- 
tion" comes  from  two  Latin  words :  e,  from,  and 
motio,  motion.  In  the  emotions  lie  that  which  moves 
to  action.  Desire,  loathing,  mirth,  sadness,  affection, 
hate,  faith,  fear  find  through  the  emotions  their  varied 
means  of  expression.  Apart  from  the  vocal  attuning 
which  the  feelings  occasion  in  speech  there  is  a  separate 
physical  language  of  the  emotions.  Witness  the 
blanched  face,  the  contracted  muscles,  the  dilated 
pupils,  and  protruding  eyes  of  Fear;  the  flushed  face 
and  swelling  throat  of  Rage;  the  anxious  or  relaxed 
and  downcast  physiognomy  of  Mental  Depression ;  the 
bright  eye,  the  clapping  hands,  and  laughing  expres- 
sion of  Pleasure ;  the  cooing  sound  of  Satisfaction. 

The  emotions  lie  close  to  the  organic  (bodily)  func- 
tions. They  find  their  quick  reflex  in  the  muscular 
expressions  of  fright,  pleasure,  despair,  and  comfort, 
already  referred  to,  as  the  idea  of  unemotional  char- 
acter finds  its  slower  expression  by  the  organs  of 
speech  or  voluntary  action.  Displaying  in  themselves 
the  earliest  states  of  consciousness,  the  emotions  are 
among  the  first  to  suffer  in  mental  disease,  as  will  be 
hereafter  shown.  The  individual  breaking  down  with 
mental  disease  reacts  to  painful  or  pleasurable  impres- 
sions with  an  unaccustomed  intensity. 

Emotional  states  are  accompanied  by  certain  phe- 
nomena referable  to  the  action  of  the  so-called  sym- 
pathetic nervous  system.  This  consists  of  a  double 
chain  of  ganglia  extending  from  the  base  of  the  brain 
along  the  sides  of  the  spinal  column  to  its  tip  and  of 


30  PSYCHOLOGY. 

certain  ganglia  scattered  among  the  organs  of  the 
chest,  abdomen,  and  pelvis.  Fibers  from  the  sym- 
pathetic are  distributed  throughout  the  body  generally ; 
indeed,  more  generally  perhaps  than  those  of  the  cere- 
bro-spinal  system.  Their  function  seems  to  be  emotive 
and  nutritive.  They  go  to  the  stomach  and  intestines. 
(Everybody  knows  that  bad  news  arrests  the  digestive 
processes.)  They  are  distributed  abundantly  in  the 
heart.  (We  speak  of  heart-sickness,  of  heart-break.) 
They  control  the  caliber  of  the  blood-vessels.  (Hence 
the  flush  of  embarrassment,  the  pallor  of  rage.)  They 
are  distributed  to  the  radiating  surface  of  the  iris 
(whence  comes  the  pupillary  dilatation  of  fear).  They 
supply  the  kidneys  (the  increase  of  whose  function  is 
so  notably  affected  through  fear).  They  govern  other 
glandular  secretions.  (Under  emotional  stress  the 
mouth  grows  dry  and  parched,  and  in  rage  the  nursing 
mother's  milk  becomes  unfit  food  for  the  offspring.) 
Emotional  states  are  attended  by  characteristic  mus- 
cular movements.  The  teeth  are  set  in  anger,  the  eyes 
opened  widely  in  deprecation,  the  brow  corrugated  in 
pain,  the  nose  elevated  in  contempt,  the  head  uncon- 
sciously oscillated  under  humiliating  recollections.  The 
shrug  which  accompanies  doubt  or  misgiving,  the  atti- 
tudes of  prayer,  of  pleading,  of  remorse,  of  prediction, 
the  wringing  of  the  hands  in  despair,  the  clapping  in 
appreciation,  are  universal  modes  of  emotional  expres- 
sion. Among  members  of  the  unfortunately  designated 
"brute  creation"  the  horse  neighs ;  the  cat  purrs  with 
satisfaction;  the  dog  wags  his  tail  in  pleasure,  lowers 
his  ears  in  chagrin,  and  displays  his  teeth  when  threat- 
ening. In  the  feathered  family  the  peacock  is  notori- 


PSYCHOLOGY.  31 

ous  for  the  exhibition  of  vanity,  the  cock  for  strutting 
in  triumph,  the  goose  for  shallow  defiance. 

The  relation  of  emotion  in  the  abstract  to  muscular 
expression  is  profitable  for  study,  not  only  because  of 
its  psychological  interest,  but  because  of  its  practical 
bearing  upon  human  conduct.  Clench  the  fist  and  shut 
the  teeth  firmly  and  there  immediately  arises  in  con- 
sciousness a  sense  of  resentment,  of  pugnacity.  Draw 
down  the  corners  of  the  mouth  and  the  emotional  tone 
takes  on  a  shade  of  depression.  Elevate  them  and  a 
pleasurable  sensation  follows.  This  has  an  important 
relation  to  mental  development.  To  cultivate  the  mus- 
cular play  that  accompanies  pleasurable  states  must  in- 
evitably affect  the  disposition  of  the  individual  in  a 
favorable  manner.  Apropos  of  this,  one  patient  who 
was  highly  tearful  was  advised  to  assume  a  happy 
expression  and  this  couplet  was  quoted  to  him : — 

"Laugh  and  the  world  laughs  with  you, 
Weep  and  you  weep  alone." 

"That's  all  very  well,"  he  said,  "but  it's  written  dif- 
ferent nowadays.  Now  it  is  'Weep  and  the  world 
laughs  at  you.' >: 

Sitting  in  my  room,  distant  from  the  window,  memo- 
ries connected  with  the  automobile  are  revived  by  the 
auditory  percept  "honk  honk."  The  sound  of  hoofs 
upon  the  pavement  perceived  at  the  same  time  is  sud- 
denly arrested,  screams  are  heard,  and  there  is  a  crash- 
ing noise.  I  am  re-minded  (memory  concepts  re-col- 
lected) that  one  of  my  family  expected  to  drive  out  at 
this  hour.  I  am  impressed  that  the  sound  of  hoofs 
resembled  those  of  my  peculiarly  gaited  horse  and  that 
the  "honk  honk"  proceeded  from  a  horn  an  auxiliary 


32  PSYCHOLOGY. 

to  the  automobile  of  a  friend.  Associating  concepts 
by  reasoning,  the  judgment  is  formed  that  there  has 
been  an  accident  and  the  emotion  (Feeling)  of  fear 
inspires  desire  to  investigate.  I  will  to  verify  or  dis- 
prove the  judgment  by  adding  new  visual  percepts,  and 
hastily  make  my  way  to  the  window. 

There  are  here  present 

Percepts  and  percept  association, 

Percept  association  with  memory  aid  (Ideation), 

Concept  association  (Reasoning), 

Judgments,  the  result  of  concept  association, 

Emotion  inspired  by  concept  association,  and 

Volition  prompted  thereby. 

Feelings  call  forth  desire.  DESIRE  forms  the  con- 
necting link  between,  feeling  and  that  which  is  next  to 
be  considered,  viz. : — 


Volition. 

VOLITION  may  be  defined  as  action  prompted  by 
desire  and  representing  choice.  Thus,  it  is  to  be  dis- 
tinguished from  all  other  forms  of  action  not  so 
prompted:  from  simple  reflex  action,  already  spoken 
of,  and  from  higher  reflex  (automatic)  action. 

In  speaking  of  perception  in  the  child,  reference  was 
made  to  the  operation  of  taking  food.  At  first  this  was 
an  unconscious  and  purely  reflex  act.  There  was  trans- 
mitted to  the  child  a  nervous  mechanism'  that,  excited 
by  the  presence  of  the  nipple  to  the  lips,  occasioned  the 
muscular  act  of  sucking.  Through  inherited  trans- 
mission the  child  was  endowed  with  this  simple  instinc- 
tive power.  Through  ages  the  nervous  mechanism  in 


PSYCHOLOGY.  33 

use  in  the  appropriation  of  food  has  acted  in  definite 
ways,  and  nervous  channels,  so  to  speak,  have  resulted. 
Sensory  impulses  have  traveled  from  lips  and  tongue 
to  the  cerebral  sensory  centers;  they  have  been  re- 
flected upon  motor  centers,  and  traveled  back  along  the 
motor  nerves  to  groups  of  muscles  about  the  tongue 
and  throat.  Impressions  registered  in  the  organic 
memory,  and  action  prompted  thereby  have  enabled 
the  appropriation  of  food  to  go  on  until  such  time  as 
desire  impels  and  voluntary  action  permits  the  gratifi- 
cation of  appetite.  This  constitutes  one  of  the  few 
inheritances  of  the  human  infant. 

The  organic  memory  of  pain  and  the  reflex  act  of 
crying  (the  expression  of  pain  in  the  absence  of  con- 
scious suffering)  is  another  inherited  quality.  It  is  the 
organic  sensation  of  hunger,  which  expresses  the  de- 
mand on  the  part  of  the  system  for  food,  that  impels 
to  the  taking  of  food  before  there  is  conscious  recogni- 
tion on  the  part  of  the  child  of  its  own  wants  or  the 
ability  to  gratify  them.  Later  on,  voluntary  action — 
action  prompted  by  desire  and  determined  by  choice — 
appears.  Compare  the  child  with  the  chick,  which, 
immediately  after  emerging  from  the  shell,  walks 
about  in  search  of  food  and  picks  it  up,  takes  refuge 
under  its  mother's  wing  when  called,  or  flees  from  the 
cat,  and  displays,  from  the  first,  adaptabilities  and 
powers  which,  in  the  child,  are  the  result  of  education. 
Mental  development,  except  under  rare  circumstances, 
however,  goes  little  further  in  the  chick.  It  is,  in  all 
essential  respects,  the  mature  animal.  It  is  through 
prolonging  the  period  of  infancy  that  evolution  has 
brought  about  in  mankind  the  capacity  for  high  mental 
development. 


34  PSYCHOLOGY. 

Again,  certain  acts  which  the  child  laboriously  and 
tediously  acquires  become,  by  the  assistance  of  the  or- 
ganic memory,  automatic  in  their  character.  Take  the 
illustration  of  walking:  It  is  in  the  child  the  result 
of  slow  education  of  the  nervous  centers.  Behind  it 
there  is  at  first  a  feeling  of  desire  to  walk ;  then  comes 
the  education  of  the  voluntary  muscles  of  locomotion. 
Eventually,  by  means  of  the  nervous  channels  estab- 
lished in  the  brain  and  cord,  walking  is  carried  on 
automatically,  the  initiation  of  the  movement  only 
being  voluntary.  The  child  walks,  runs,  and  turns 
about,  all  without  the  conscious  exercise  of  volition. 
Contact  with  the  ground,  the  sensory  impulse  proceed- 
ing by  the  way  of  the  spinal  cord  to  the  brain,  its  recep- 
tion by  the  sensory  centers,  its  reflection  upon  the 
motor  centers,  and  through  the  motor  nerves  to  the 
muscles  concerned  in  the  act,  are  the  steps  in  the 
process. 

So  of  self-defensive  acts.  At  first  the  child  re- 
quires to  be  protected  from  all  manner  of  harm. 
Later,  through  education,  it  acquires  self-defensive 
ability  and  involuntarily  shields  itself  from  that  which 
threatens.  One  is  conscious  of  averting  danger,  or  of 
taking  self-defensive  measures,  oftentimes  after  the  act 
is  completed.  He  raises  the  arm  to  ward  off  a  blow 
and  sensing  (not  perceiving)  a  stumble  he  throws  him- 
self from  the  saddle  and  alights  on  his  feet  as  the  horse 
falls.  All  sorts  of  habits  of  life  are  thus  formed. 
Winding  the  watch  before  retiring  frequently  takes 
place  without  consciousness.  The  act  of  locking  or 
unlocking  a  door  is  done  automatically.  Piano-playing, 
an  accomplishment  tediously  acquired,  is  finally  carried 
on  through  the  organic  memory  without  appreciable 


PSYCHOLOGY.  35 

voluntary  effort  except  in  the   act  at  its  beginning. 
These  are  higher  cerebral  reflex  acts. 

The  Higher  Volition,  like  the  other  faculties  of 
mind,  is  a  plant  of  slow  growth,  and  involves  discrimi- 
nation, comparison,  weighing  of  ideas,  and  judgment 
as  to  the  best  course  to  pursue.  It  is  difficult  to  deter- 
mine when  the  child  first  exercises  volition.  The 
choosing  between  that  which  is  sweet  and  that  which  is 
without  marked  flavor,  but  better  for  his  needs,  is,  to 


Illustration  of  volition. 

be  sure,  an  action  prompted  by  desire;  but  the  higher 
volition  implies  discrimination  between  that  which  is 
profitable  and  that  which  is  unprofitable.  Cultivation 
of  the  reasoning  and  judgment  are  necessary  to  this. 

The  education  of  the  will  is  most  important  to  the 
future  of  the  child.  The  matured  judgment  places  an 
inhibition — a  restraining  influence — upon  the  actions, 
that  decision  between  that  which  is  ultimately  good  and 
that  which  is  immediately  gratifying  may  result.  It 
may  be  a  source  of  present  satisfaction  to  smite  in  the 
face  one  who  has  injured  me,  but  the  higher  volition 
restrains  the  act. 

The  law  rightly  makes  distinction  between  impulsive 
acts  and  those  prompted  by  deliberation  and  choice 


36  PSYCHOLOGY. 

One  in  the  heat  of  passion  kills  another  who  has  seri- 
ously wronged  him.  Here  the  judgment  was  obscured 
by  the  emotional  feeling,  and  a  muscular  act  resulting 
in  death  occurred.  On  the  contrary,  brooding  over  a 
wrong,  one  deliberately  decides  to  kill,  and  carries  his 
plan  into  execution.  In  the  one  case  the  act  was  semi- 
instinctive,  self-defensive  in  a  way.  It  was  prompted 
by  sudden  resentment,  and  the  emotion  obscured  the 
judgment.  Result:  manslaughter.  In  the  other  case 
there  was  a  deliberate  choosing,  a  careful  adaptation 
of  means  to  ends,  a  judgment  and  a  will  to  kill.  This 
was  murder. 

It  is  important  to  distinguish  between 

Simple  Reflex  Acts, 

Higher  Reflex  Acts, 

Volitional  Acts,  and 

Inhibitory  Acts  (a  variety  of  the  volitional). 

The  first — Simple  Reflex  Acts — are  instinctive:  as 
the  involuntary  withdrawal  from  contact  with  that 
which  is  painful ;  winking ;  breathing. 

The  second — Higher  Reflex  Acts — were  originally 
voluntarily  acquired — learned — but,  once  learned,  go 
on,  in  a  measure,  automatically,  the  volition,  if  exer- 
cised at  all,  merely  initiating  the  movement:  as  the 
act  of  walking. 

Volitional  Acts  are  those  which  spring  from  desire 
and  represent  choice:  as  the  putting  on  of  rubbers  in- 
wet  weather,  to  protect  health. 

Inhibitory  Acts — a  variety  of  volitional  acts — are 
those  which,  check  the  immediate  response  to  desire  and 
impulsion,  and  introduce  a  restraining  influence — a 
"will  not  to  do,"  so  to  speak.  The  higher  volitional 
and  inhibitory  acts  imply  the  exercise  of  judgment. 


PSYCHOLOGY.  37 

LIMITATIONS  OF  THE  WILL. 

1.  The  will  has  no  prolonged  power  over  involuntary 
muscles.     Let  one  try  to  stop  breathing,  and  demon- 
strate this  for  himself. 

2.  The  will  does  not  control  movements  which  have 
not  been  acquired  by  practice.     One  may  satisfy  him- 
self of  the  truth  of  this  in  his  first  bicycle  ride. 

3.  Painful  thoughts  cannot  be  dismissed  from  the 
mind  by  an  effort  of  the  will.     They  must  be  sup- 
planted and  crowded  out  by  introducing  others. 

General  Considerations. 

All  of  the  foregoing  has  its  bearing  upon  the  study 
of  mental  disease.  In  insanity  any  or  all  of  the  func- 
tions of  the  mind  may  be  disturbed. 

Any  or  all  of  the  elemental  processes  of  sensation, 
perception,  -ideation,  reasoning,  judgment,  memory, 
may  be  impaired.  Upon  the  integrity  of  these  ele- 
mental processes  and  those  of  emotion  and  volition  de- 
pends our  normal  relation  to  our  environment,  and  it  is 
interesting  to  consider  from  a  psychological  standpoint 
in  what  manner  and  to  what  degree  these  elemental 
processes  are  disturbed  in  different  states  of  mental  ex- 
citement, depression,  or  weakness. 

SENSATION  may  be  impaired  or  lost.  The  special 
senses  of  taste  and  smell  may  be  so  much  at  fault  that 
the  vilest  substances  placed  in  the  mouth  do  not  excite 
disgust.  In  such  a  case  PERCEPTION  also  fails.  Faulty 
perception  may  further  manifest  itself  in  Hallucina- 
tions and  Illusions. 

Sensation  is  altered  or  lost  in  hysteria,  in  epilepti- 
form  states,  in  pseudoparetic  states  dependent  upon 


38  PSYCHOLOGY. 

syphilis  and  alcoholism,  and  in  the  various  forms  of 
dementia.  It  is  a  matter  of  experience  that  sensation 
may  travel  more  slowly  and  be  less  acute  in  the  men- 
tally diseased  than  in  the  healthy  individual.  Sensation 
is  impaired  in  apathetic  conditions,  is  increased  in 
maniacal  states,  in  delirious  states,  and  in  the  frenzied 
periods  accompanying  certain  forms  of  manic-de- 
pressive insanity. 

Perception  is  perverted  in  certain  manic-depressive 
states,  is  delayed  in  apathetic  states,  is  transformed 
into  hallucinatory  states  in  acute  excitement  and  de- 
pression, in  different  forms  of  delirium,  in  paranoia, 
in  dementia  prsecox,  and  in  organic  brain  disease,  but 
may  be  outwardly  undisturbed  in  the  recurrent  type  of 
manic-depressive  insanity. 

A  Hallucination  is  a  false  perception  without  an  ob- 
jective reality.  Example :  One,  looking  upon  the  bare 
floor,  fancies  he  sees  a  snake.  There  is  nothing  what- 
ever upon  the  floor  which  could  lead  to  that  perception. 
He  is  suffering  from  a  visual  Hallucination. 

One  looks  upon  a  carpet  with  bright  figures  and 
irregular  tracings,  and  sees  in  the  bright  figures  birds 
of  brilliant  plumage,  and  in  the  tracings  of  duller  colors 
snakes  or  rats.  He  is  suffering  from  an  Illusion,  that 
is,  a  false  perception  with  an  objective  reality. 

He  hears  the  sound  of  steam  escaping  from  the 
radiator,  and,  in  this  sound,  the  voice  of  some  one 
threatening  to  kill  him;  in  the  ticking  of  his  watch 
he  hears  commands ;  in  the  locomotive  whistle  he  per- 
ceives calls  and  shrieks.  He  is  suffering  from  illusions 
of  hearing.  He  hears  a  cry  when  all  is  still;  he  has 
an  auditory  hallucination.  Thus,  in  smell,  taste,  touch, 
and  the  muscular  sense  hallucinations  and  illusions 


PSYCHOLOGY.  39 

may  develop.  The  weight  of  the  bedclothes  may  give 
the  impression,  through  the  muscular  sense,  of  a  heavy 
load ;  or  one  may  fancy  himself  exerting  great  muscu- 
lar strength,  may  even  perspire  and  become  manifestly 
exhausted  through  efforts  to  sustain  bodies  which  in 
fancy  are  burdening  him,  while,  in  fact,  he  is  entirely 
free  from  any  weight  or  pressure. 

Hallucinations  of  hearing  exist  in  insane  patients 
who  have  deafness,  acquired;  of  vision,  in  those  who 
have  become  blind:  there  could  be  no  better  illustra- 
tion of  the  fact  that  we  hear  and  see  with  the  brain — 
the  mind — not  with  the  eye  and  ear.  The  inference 
follows  that  hallucinations  of  hearing  or  vision  in  one 
congenitally  deaf  or  blind  would  be  impossible — the 
cerebral  centers  which  preside  over  these  senses  in 
health  never  having  been  in  action.  No  true  concep- 
tion of  sound  can  exist  in  one  congenitally  deaf,  or  of 
color  in  one  totally  blind  from  birth.  Consequently 
no  hallucination  can  be  present.1 

1  In  the  Journal  of  Mental  Science  for  July,  1895,  an  inter- 
esting account  is  given  of  the  hallucinations  of  a  deaf  para- 
noiac. The  case  reported  by  Dr.  Cramer  to  the  Psychiatric 
Association  at  Berlin  is,  in  brief,  as  follows:  He  was  37 
years  old  and  had  been  born  deaf ;  but  had  been  educated  and 
learned  to  be  a  portrait-painter.  When  admitted  to  the 
asylum  at  Eberswalde  he  was  much  excited  'and  violent.  "He 
was  very  suspicious,  not  at  all  communicative,  and  very  diffi- 
cult to  handle.  In  about  ten  months  he  began  to  improve 
and  engaged  in  outdoor  work.  A  year  afterward  he  again 
resumed  -his  painting  and  was  willing  to  converse.  Dr. 
Cramer  framed  a  number  of  questions  which  the  deaf  man 
answered  in  writing.  Instead  of  hallucinations  of  hearing,  for 
he  could  not  hear,  he  imagined  that  communications  were  made 
to  him  by  the  ordinary  signs  used  by  the  dumb,  and  through 
the  words  which  he  had  been  taught  to  utter  by  muscular 


40  PSYCHOLOGY. 

Hallucinations  and  illusions  give  rise  to  Delusions. 
Hallucinations  may  be  present  in  the  mind  of  one  not 
insane.  As  long  as  they  are  corrected  by  the  reasoning 
and  judgment  they  do  not  amount  to  delusions.  Be- 
lieved in,  however,  and  present  because  of  a  diseased 
condition,  they  become  delusions. 

A  Delusion,  therefore,  is  a  false  belief  due  to  disease. 
The  qualification  "due  to  disease"  is  introduced  be- 
cause there  are  multitudes  of  false  beliefs  in  the  world 
not  due  to  disease,  but  to  faulty  education,  as  the 
beliefs  in  witchcraft,  satanic  possession,  the  evil 
eye,  the  visitation  of  ghosts,  the  so-called  "Christian 
science,"1  etc.  In  estimating  the  importance  of  a  false 
belief  as  bearing  upon  the  mental  state  of  the  subject, 
it  is  necessary  to  take  into  consideration  his  natural 


exercises  of  the  mouth  and  throat,  and  also  by  studying  the 
motions  of  the  lips  in  others.  In  these  ways  he  thought  that 
obscure  ideas  were  introduced  to  his  mind.  Cramer  took 
occasion  to  observe  that  it  was  air  error  to  believe  that  in  all 
our  thinking  heard  words  are  used.  In  this  he  is  convinced 
that  there  are  great  differences,  some  even  transacting  thought 
through  the  acoustic  form  of  words,  others  through  the  re- 
vival of  images  formed  from  the  movements  of  the  organs 
of  speech  or  the  sensation  of  accomplished  muscular  efforts." 
i-  — ,  111.,  February  23.— Mrs.  —  -  died  here 

a  few  days  ago  after  a  brief  illness  of  inflammation  of  the 
bowels.  She  and  her  husband  and  other  members  of  the 
family  were  Christian  scientists.  An  attempt  was  made  to 

cure  Mrs. by  prayer  and  other  practices  usually 

resorted  to  by  members  of  that  faith  before  summoning  a 
regular  physician.  The  physician  was  called  too  late  to  be 
able  to  render  any  assistance.  It  is  thought  by  the  neighbors 
and  friends  of  the  deceased  that  the  woman  could  have  been 
saved  if  medical  aid  had  been  summoned  sooner. — Press 
Report. 


PSYCHOLOGY.  41 

habits  of  thought,  his  previous  education  and  mode  of 
life.  A  philosopher  suddenly  expressing  a  belief  in 
witches  might  be  justly  regarded  as  having  an  insane 
delusion.  It  would  not  be  safe  to  conclude,  however, 
in  the  case  of  an  illiterate  Southern  negro,  that  an  ex- 
pression of  belief  in  witchcraft  implied  insanity.1 

A  venerable  priest  ministering  to  the  necessities  of 
the  members  of  a  fast-disappearing  tribe  of  Indians, 
on  the  lower  St.  Lawrence,  told  me  of  unique  methods 
formerly  in  vogue  among  them  for  overcoming  the 
evil  spirit  "Wendigo"  supposed  to  possess  the  body  of 
one,  insane  and  eat  out  the  souls  of  others.  It  was  the 
aim  of  the  Indians  to  lose  in  the  woods  or  otherwise 
dispose  of  one  afflicted  with  a  mental  infirmity.  On 
one  occasion  the  priest  heard  by  chance  of  a  puerperal 
woman  suffering  from  mania.  Approaching  her  cabin 
about  which  many  "braves"  were  standing,  he  heard 
the  words  "the  cure  is  coming."  The  reason  for  the 
warning  was  soon  apparent.  Inside  the  cabin  he  dis- 
covered the  Indian  woman  bound  to  a  chair  placed 
back  up  and  in  a  sloping  position.  Round  her  neck 
was  a  cord  which  extended  through  a  chink  in  the  rear 
wall  of  the  cabin.  At  the  other  end  of  this  cord  there 


1  A  young  woman  named  Lynch,  a  light-skinned  negress, 
who  resides  in  a  cottage  in  the  suburbs  of  Washington,  is 
causing  a  stir  hereabouts,  for  she  is  suspected  of  being  a 
witch.  The  charge  comes  directly  from  Hannah  Johnson,  an- 
other negress,  who  claims  the  Lynch  woman  cast  a  spell  upon 
her,  stealing  her  sight.  The  only  direct  evidence  is  merely 
circumstantial.  The  Johnson  woman  suddenly  has  gone 
blind.  She  blames  the  light-skinned  negress  for  her  misfor- 
tune and  has  preferred  charges  of  witchcraft,  which  the 
superstitious  negroes  of  the  community  are  commencing  to 
believe.— Detroit  Free  Press,  April  20,  1913. 


42  PSYCHOLOGY. 

had  been  relays  of  Indians,  who  made  it  taut  from 
time  to  time.  The  priest  extricated  the  squaw  from 
her  perilous  position,  soothed  and  cared  for  her.  Not 
long  after,  however,  with  the  characteristic  perversity 
of  one  partially  appreciating  the  reason  for  the  atten- 
tion her  neighbors  had  bestowed  and  to  the  end  defiant, 
she  exclaimed :  "Now  I  will  eat  your  hearts  out." 

The  same  expression  from  two  different  sources  may 
be,  in  the  one  instance  the  result  of  ignorance  or 
viciousness,  in  the  other  due  to  a  delusion.  Thus,  the 
denunciation  of  religious  orders  by  a  blatant  anarchist 
might  be  disregarded  as  having  no  bearing,  neces- 
sarily, on  his  mental  condition,  while  allegations  of 
misdoing  in  such  orders  coming  from  one  identified 
with  and  theretofore  sentimentally  interested  in  them 
might  furnish  excellent  ground  for  the  suspicion  that 
his  mental  operations  were  disturbed.  For  example, 
while  it  is  by  no  means  beyond  belief  that  a  bishop  may 
be  corrupt  and  licentious  and  because  of  these  failings 
tolerant  of  the  transgressions  of  priests  in  his  diocese, 
or  that  the  sister  superior  in  charge  of  a  hospital  may 
be  addicted  to  drink  or  the  use  of  opium,  it  would  be 
extraordinary  if  these  charges  were  publicly  made  by 
a  priest  against  his  bishop,  his  brother  priests,  and  the 
head  of  a  nursing  order ;  and  while  freedom  of  speech 
is  an  inborn  right  of  the  American  citizen,  it  is  difficult 
to  believe  that  one  brought  up  under  the  rigid  disci- 
pline of  the  priesthood  could  in  his  sober  senses  refer 
to  ecclesiasticism  as  "akin  to  diabolism."  Such  ex- 
pressions from  such  a  source  would  be  strongly  indic- 
ative of  departure  from  the  normal  standard  of  think- 
ing, feeling,  and  acting.  At  the  same  time  I  have 
known  physicians  who,  carried  away  by  the  logic,  the 


PSYCHOLOGY.  43 

apparent  sincerity,  the  beautiful  diction,  and  the  con- 
tinuity of  narrative,  have  failed  to  discover  anything 
insane  in  allegations  like  these,  and  have  ignored  glar- 
ing inconsistencies  in  a  story  because  of  the  forceful 
language  in  which  it  was  told. 

In  cases  of  manic-depressive  insanity  of  the  recur- 
rent type,  the  physician's  services  are  oftenest  in  de- 
mand during  the  excited  period.  The  conduct  of  the 
patient  is  mischievous  and  trying.  He  seems  actuated 
by  the  spirit  of  evil,  and  goes  out  of  his  way  to  make 
trouble  for  his  relatives  and  neighbors.  He  places 
wrong  construction  upon  innocent  conduct  and  re- 
marks, he  carries  tales  from  one  to  another,  and  em- 
bellishes them  with  satanic  ingenuity,  just  keeping 
within  the  bounds  of  possible  truth.  Egotism,  self- 
sufficiency,  and  intolerance  are  displayed  in  language 
and  lineament,  but  such  patients  are  so  clever  that  it 
is  often  impossible  to  extract  definite  delusions  in 
ordinary  conversation.  Here  there  is  also  danger  of 
being  deceived  by  externals.  The  patient  makes  all 
sorts  of  reasonable  explanations  of  erratic  and  insane 
conduct,  he  alleges  cruelty  and  abuse  as  causes  for  out- 
bursts of  ill-feeling  or  resentment.  He  claims  there  is 
conspiracy  to  deprive  him  of  his  property.  Toward 
his  relatives,  to  whom  he  ascribes  unworthy  motives, 
he  displays  a  subtle  ingenuity  in  making  trouble.  With 
the  medical  examiner  he  conceals,  evades,  and  covers 
up,  and  in  court  he  may  possibly  conduct  his  own  case 
to  the  witnesses'  very  great  discomfiture.  In  the  con- 
dition of  depression,  however,  he  is  remorseful  for 
incidents  of  excitement,  and  is  introspective  and  self- 
depreciatory. 

Different  degrees  of  disturbance  of  reasoning  and 


44  PSYCHOLOGY. 

judgment  may  occur,  dependent  upon  the  form  of  men- 
tal disease  encountered.  The  existence  of  delusions 
implies  morbid  reasoning  and  judgment.  Delusions 
may  have  their  origin  in  false  perceptions  and  the  at- 
tempts to  explain  painful  or  pleasurable  sensations. 
Reasoning  in  mental  disease  is  not  always  illogical.  It 
may  be  fairly  correct  and  from  false  premises  as  in 
paranoia,  or  be  entirely  correct  concerning  everything 
apart  from  the  individual  as  in  the  depressed  form  of 
manic-depressive  insanity.  Reasoning  and  judgment 
are  disturbed  in  delirious  and  maniacal  states,  and  are 
slowly  impaired  and  lost  in  the  dementias,  particularly 
those  of  organic  form. 

IDEATION  is  slow  in  depression,  in  the  dementias,  in 
different  forms  of  organic  brain  disease,  and  in  the 
later  stages  of  alcoholism  and  opium  intoxication.  It 
is  quickened  in  the  early  stages  of  opium  taking,  alco- 
holic intoxication,  and  in  all  forms  of  maniacal  excite- 
ment. In  acute  maniacal  states  it  is  often  so  very 
much  quickened  that  incoherence  results ;  this  is  due  to 
the  rapid  change  of  concepts  and  the  hurried  speech 
necessary  to  their  expression.  In  manic-depressive 
(recurrent)  type  during  the  excited  period  it  may  be 
unduly  active. 

The  MEMORY  may  be  at  fault,  both  in  the  recollec- 
tion of  percepts  and  in  the  registration  of  organic  sen- 
sations, as  heretofore  mentioned  in  connection  with  the 
personality. 

The  memory  is  confused  or  may  be  temporarily  ob- 
literated in  maniacal  states,  may  be  undisturbed  in 
those  of  depression,  is  lively  in  paranoia,  and  impaired 
and  finally  abolished  in  various  forms  of  organic  brain 
disease  and  in  the  senile  insanities.  The  existence  of 


PSYCHOLOGY.  45 

serious  memory  defect  is  always  to  be  viewed  with 
alarm.  In  dementia  from  senile  causes,  as  is  well 
known,  there  may  be  fairly  accurate  memory  for  re- 
mote events,  but  none  for  those  of  recent  occurrence. 

The  EMOTIONS — feelings — may  be  at  fault.  As  pre- 
viously mentioned,  disturbance  of  the  emotions  is  an 
early  manifestation  of  mental  disease  in  many  of  its 
forms. 

In  the  graver  forms  of  insanity,  associated  with 
nervous  degeneration,  the  HIGHER  REFLEXES  (the  co- 
ordination) are  disturbed. 

VOLITION,  which  in  conditions  of  sanity  is  checked 
and  governed  by  the  judgment,  may  be  abolished  or 
very  much  impaired.  Examples :  The  irregular  mus- 
cular movements,  shifting  glance,  and  inattentiveness 
in  maniacal  excitement ;  the  unwillingness  to  put  forth 
muscular  effort  in  morbid  depression. 

The  natural  expression  of  volition  depends  upon 
attention  and  free  association  of  concepts. 

1.  Inattentiveness,  Incoherence,  Flight  of  Ideas, 
Verbigeration,  Stereotypy. 

The  ability  to  concentrate  attention  is  impaired  to 
a  greater  or  less  extent  in  all  forms  of  mental  disease. 
In  those  in  which  the  dominating  emotional  note  is 
acutely  painful,  the  lack  of  ability  arises  from  the  feel- 
ing that  nothing  is  worth  while,  from  quickly  oncoming 
fatigue,  from  preoccupation  with  what  is  going  on 
within,  from  agitation  over  distressing  concepts.  In 
other  states  of  depression  with  emotional  reduction,  it 
is  due  to  apathy,  dullness,  or  indifference.  In  delirium, 
in  maniacal  states,  and  in  those  conditions  where  pro- 
nounced confusion  exi-sts  attentiveness  may  be  but 
momentary  and  inability  to  concentrate  due  to  the 


46  PSYCHOLOGY. 

interplay  of  disordered  and  unrelated  concepts,  any 
incidental  auditory,  visual,  or  tactile  impression  calling 
faintly  into  being  some  concept,  which  immediately 
finds  expression  in  speech.  The  sound  of  the  final 
syllable  of,  or  some  determining  word  of,  a  sentence 
suggests  another  related  by  association,  this  in  turn 
another,  and  so  on  to  chaos  in  expression  (incoher- 
ence), or  concept  association  calls  forth  entire  sen- 
tences of  longer  or  shorter  length,  distantly  related,  but 
without  close  dependence  and  leading  nowhither  (flight 
of  ideas).  Or  the  presence  of  words  of  similar  sound 
determines  repetition  again  and  again  of  some  sentence 
or  fragment  of  a  sentence,  or  meaningless  rhyme. 
When  having  to  do  with  word  repetition,  this  is  called 
verbigeration.1 

A  similar  symptom,  stereotypy*  may  also  display  it- 
self in  the  motor  sphere  of  speech,  and  elsewhere,  as 
in  rigidity  of  certain  groups  of  muscles,  purposeless 
movements  of  a  rhythmical  character,  peculiar  attitudes 
in  walking,  and  resistance  to  the  natural  tendencies  of 
muscular  expression.  In  paranoia  and  certain  para- 
noid states  inattentiveness  may  arise  from  the  feeling 
on  the  part  of  the  individual  of  the  superiority  of  his 
own  outgivings  to  those  of  other  people  and  impatience 
in  listening  to  what  he  regards  unimportant  and  in- 
consequential. 

1 1  am  aware  that  these  terms  have  been  employed  in  a  less 
restricted  signification,  but  it  seems  more  logical  to  me  to  limit 
the  application  of  verbigeration  to  the  repetition  of  the  same 
word  or  of  words  of  similar  sound;  stereotypy,  to  sentence 
repetition  and  to  muscular  movements  of  the  same  character 
made  again  and  again  without  variation. 


PSYCHOLOGY.  47 

Seven  minutes  of  ten. 

I  hear  that  voice. 

I  hear  that  voice. 

I  hear  that  voice. 

I  hear  that  voice. 

Take  nurse  from  hall. 

Take  nurse  from  hall. 

Take  nurse  from  hall. 

Take  nurse  from  hall. 

My  mother  is  safe 

My  mother  is  safe 

My  mother  is  safe 

My  mother  is  safe 

Some  one  out  side. 

Some  one  out  side. 

Some  one  out  side. 

Some  one  out  side. 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

I  am  in  pain 

She  will  not  go 

We  are   all   God's   children.     Please — please  tell  to 

come  over  right  away.     Please  please  please  please. 

Illustrations  of  stereotypy. 


48  PSYCHOLOGY. 

2.  Pressure  of  Activity,  Retardation,  Opposition, 
Negativism. 

Natural  response  to  impressions  from  without  will 
necessarily  be  altered  or  impaired  more  or  less  in  cor- 
respondence with  the  degree  in  which  fixation  of  at- 
tention is  possible.  In  certain  cases  reflex  is  slow  and 
a  considerable  interval  elapses  between  interrogatory 
and  reply,  or  suggestion  and  response.  This  symptom 
is  known  as  retardation  and  is  usually,  perhaps  in- 
variably, encountered  in  the  depressed  periods  of 
manic-depressive  insanity.  In  other  cases  response 
may  be  sudden  and  intense  and  moved  by  impressions 
from  without,  the  pressure  of  activity  from  within; 
also  a  symptom  of  manic-depressive  insanity  (the  ex- 
cited phase)  may  be  augmented. 

Response  to  suggestion  to  dress  or  disrobe,  to  rise 
or  retire,  to  take  food  or  receive  treatment,  may  fail 
through  fear  of  poison  or  personal  injury,  through 
sluggishness  of  the  mental  reflexes  (retardation), 
through  preoccupation  with  delusions  or  bizarre  con- 
cepts, or  through  resistance  to  the  will  of  others  and 
definite  determination  upon  a  contrary  course.  It  is 
important  to  differentiate  the  opposition  to  taking  food 
or  receiving  care  displayed  by  a  patient  fearful  of  in- 
jury (a  manic-depressive  case,  for  example)  from  the 
so-called  negativism — a  characteristic  symptom  of  de- 
mentia prsecox — in  which  the  patient  not  only  opposes, 
but  performs  acts  directly  contrary  to  those  suggested. 
Attempts  to  insert  his  arm  in  the  sleeve  of  his  coat 
are  met  by  persistent  tugging  at  the  free  end  of  the 
sleeve;  to  remove  the  coat,  by  his  tightly  holding  the 
two  sides  together.  Asked  to  lie  upon  the  right  side, 
he  turns  to  the  left;  given  an  enema,  he  forcibly  re- 


PSYCHOLOGY.  49 

strains  its  operation  until  apart  from  the  conveniences 
of  the  toilet  room,  or,  indeed,  ensconced  in  bed.  He 
voluntarily  refrains  from  emptying  the  bladder. 
There  is  predilection  for  the  beds,  clothing,  and 
furnishings  belonging  to  his  neighbors  and  antagonism 
toward  that  provided  for  his  own  use. 

In  closing  this  chapter,  it  seems  desirable  to  empha- 
size the  fact  that,  although  ideation,  reasoning,  judg- 
ment, memory,  volition,  and  emotional  control,  any  or 
all,  may  be  impaired  in  insanity,  it  by  no  means  fol- 
lows that  insight  into  the  condition  is  invariably  lack- 
ing on  the  part  of  the  patient.  Certain  cases  of  manic- 
depressive  insanity  are  conscious  of  the  existence  of 
unwonted  exaltation  and  respond  to  some  extent  to 
suggestion  to  hold  morbid  impulses  in  check.  Not  in- 
frequently appreciating  the  oncoming  of  lack  of  self- 
control,  they  avail  themselves  of  opportunities  offered 
for  hospital  or  sanitarium  care.  In  depressed  periods 
there  is  often  exaggerated  appreciation  of  the  condi- 
tion and  much  self-disparagement  because  of  the  con- 
sciousness of  ineptitude  and  worthlessness.  Presenile 
and  involutional  cases  entertain  lively  fears  of  "going 
insane,"  meaning  by  this  that  the  patient  anticipates 
his  present  mental  disability  will  go  over  into  complete 
lack  of  consciousness  of  his  surroundings  and  absence 
of  self-control.  Admission  of  the  fact  of  insane  con- 
duct during  a  previous  attack  is  often  in  evidence 
although  the  patient  may  deny  present  disorder  in 
thinking  or  acting.  I  have  known  a  dementia  prsecox 
patient  during  a  semilucid  period  to  aver  he  had 
"always  been  insane."  In  two  cases  of  advanced 
paretic  dementia  there  was  lively  recognition  on  the 
part  of  the  afflicted  individuals  of  the  hopelessness  of 


50  PSYCHOLOGY. 

outlook  and,  in  one  of  these,  persistent  suicidal  deter- 
mination because  of  the  gloomy  view.  Insight  is  rare, 
however,  in  the  latter  class  of  cases,  is  notably  absent 
in  true  paranoia,  and  can  rarely  be  determined  where 
there  is  marked  deterioration  in  intellect,  as  in  ad- 
vanced cases  of  dementia  prsecox. 


PART  II. 


SYMBOLISM    IN    SANITY    AND    IN 
INSANITY. 

THINKING  is  conducted  for  the  most  part,  if  not 
wholly,  in  words  or  in  their  visible  signs,  visible  signs 
standing  for  individual  words  or  comprising  whole 
'sentences,  as,  for  example,  the  shrug  of  the  shoulders 
in  dubiety  or  deprecation,  movements  of  the  head  in 
negation  or  affirmation,  and  the  muscular  expressions 
used  as  means  of  communication  by  the  dumb.  The 
trend  of  thinking  and  expression  is  with  great  fre- 
quency determined  through  ocular  percepts,  and  the 
realm  of  object  symbolism  is  far  more  extensive  than 
the  individual  is  aware  until  he  turns  attention  directly 
to  the  subject. 

From  every  object  visually  examined  springs  a  con- 
cept more  or  less  perfectly  defined,  or  an  emotion 
directly  related  to  its  physical  properties,  its  corre- 
spondences, its  uses,  its  origin,  or  its  value,  as  well  as 
many  an  indirectly  related  concept  which  its  form,  its 
purpose,  its  resemblances,  bring  into  being.  Every 
object  in  nature  is  in  a  poetic  sense  endowed  with  the 
instincts,  capacities,  and  sentiments  of  the  human 
family,  and  the  terms  descriptive  of  regional  and 
special  anatomy,  or  physiological  and  psychological 
processes,  are  transferred  to  inanimate  objects.  The 
oak  suggests  sturdiness,  ruggedness,  and  strength  of 
character.  It  has  limbs,  trunk,  and  heart.  A  fellow- 

(51) 


52  SYMBOLISM    IN   SANITY  AND   IN   INSANITY. 

citizen  of  rugged  character,  dependability,  and 
strength  of  purpose  is  said  to  possess  a  heart  of  oak. 
Spring  foliage  represents  inexperience  (verdancy)  ; 
brown  and  yellow,  decay  (the  sear  and  yellow  leaf). 
Stone  is  a  symbol  of  hardness,  and  there  are  cor- 
respondingly hearts  of  flint.  The  ascent  of  a  river  and 
the  exploration  of  a  cave  are  begun  from  the  mouth. 
The  volcano  vomits  forth  its  lava  stream,  and  the 
earth  clothes  itself  in  a  green  garment.  There  is  the 
family  tree  derived  from  the  symbol  of  trunk  (pro- 
genitor), offshoots  and  branches  (near  and  remote 
relatives).  One  goes  to  the  root  of  a  subject,  even 
as  the  tap  root  penetrates  deeply  the  soil.  The  posi- 
tion "up  a  tree"  is  embarrassing  and  difficult,  as  many 
a  cat  has  discovered. 

The  hills  are  a  symbol  of  hopefulness  and  suste- 
nance. "I  will  lift  up  mine  eyes  unto  the  hills  from 
whence  cometh  my  help."  The  sea  is  represented  by 
Schiller  as  laughing  and  inviting  to  the  bath,  and  in  its 
tempestuous  moments  it  distinctly  says  to  a  not  unduly 
imaginative  friend  of  mine  "I  am  coming  to  get  you." 
Every  region  has  its  twin  lakes ;  there  are  in  the  Yel- 
lowstone Park  Teton  Mountains;  America  has  its 
backbone;  Michigan  has  its  thumb;  Italy,  its  toe  and 
heel.  There  are  the  lap  and  bosom  and  womb  of 
nature  as  well  as  the  bowels  of  the  earth,  the  nose  of 
the  ship,  the  face  of  the  cliff,  the  brow  of  the  hill.  In 
Scripture  imagery  the  deserts  shall  rejoice  and  the 
wind  is  endowed  with  volition.  It  "bloweth  where  it 
listeth."  There  is  resurrection  of  truth  crushed  to 
earth.  The  automobile  engine  shows  distress  and 
"charity  suffereth  long  and  is  kind,"  the  attribute  in 
the  latter  instance  standing  for  the  individual  whose 


SYMBOLISM    IN   SANITY  AND  IN   INSANITY.  53 

breasts  overflowing  with  the  milk  of  human  kindness 
is  its  highly  endowed  possessor.  Nature  lovers  and 
probably  not  a  few  fakers  harken  to  the  call  of  the 
wilds  in  vacation  time,  provided  the  pinch  of  poverty 
does  not  detain  them  at  home.  One  may  experience 
the  touch  of  nature  or  that  of  defilement,  be  touched 
by  suffering,  and  touched  in  his  exchequer  through  a 
wild-cat  enterprise.  Wealth  may  come  to  all  except 
the  physician  by  leaps  and  bounds.  An  onion  has  its 
skin,  likewise  the  banana,  and  peeling  either  is  signifi- 
cant to  the  sensualist.  The  candidate  for  a  degree 
gives  head  and  body  to  his  thesis  and  the  pugilist  puts 
a  head  on  some  portion  of  his  antagonist's  body. 
There  are  the  head  of  the  church,  the  head  of  the  pro- 
cession, the  head  of  the  lake,  and  a  long,  heavy  train 
drawn  by  two  locomotives  is  designated  a  double- 
header.  'There  are  the  neck  of  land,-  the  eye  single  to 
that  which  is  good,  the  jaws  of  an  instrument,  the 
chest  of  tools,  the  lip  of  scorn,  the  finger  of  destiny. 
Little  pitchers  have  ears,  the  sea  arms,  the  waves  a 
voice,  the  mountain  a  foot,  a  comet  head  and  tail,  the 
potato  eyes.  Plumbers  use  male  and  female  fittings, 
nipples  and  elbows  in  their  vocation.  Human  sym- 
pathy has  breadth,  affection  depth,  folly  height.  A 
character  is  spoken  of  as  well  rounded;  sarcasm,  as 
pointed.  Duty  calls,  happiness  rains,  the  stone  has  a 
face,  and  the  elements  on  occasions  display  anger. 
Dispositions  are  sweet  and  sour ;  certain  forms  of  jest- 
ing leave  a  bitter  taste.  One  scents  trouble.  One  does 
not  require  a  sleeping  car  to  negotiate  the  distance  be- 
tween Paradise  Valley  and  Devil's  Lake,  and  need  not 
ordinarily  waste  trolley  fare  in  a  trip  from  poverty 
flats  to  nob  hill.  It  would  not  be  necessary  to  delve 


54  SYMBOLISM   IN   SANITY  AND  IN   INSANITY. 

deeply  for  the  origin  of  the  expression  "they  do  not 
hit  it  off  together"  used  in  the  politest  conversation  as 
concerning  two  antipathetic  individuals.  Certain  char- 
acters are  designated  as  flabby  and  certain  heads  as 
soft.  The  sun  rules  by  day,  the  moon  and  stars  by 
night,  and  the  moon  governs  the  tides. 

The  May  pole  is  said  to  be  a  survival  of  phallic 
adoration.  One  is  understood  to  be  a  good  swords- 
man if  his  weapon  of  offense  is  adjusted  to  more  than 
one  sheath,  and  different  fur-bearing  animals  sym- 
bolize sexual  parts.  The  older  members  of  the  pro- 
fession will  recall  the  imaginative  expression  "nest 
hiding"  as  mentioned  in  a  notorious  ecclesiastical  trial 
of  many  years  ago.  A  sound  and  meritorious  bill  may 
be  emasculated  in  committee  and  the  virility  lost  from 
a  burning  question  by  ineffective  discussion.  We  are 
interested  in  living  issues  and  attend  obsequies  of  the 
dead  past.  There  is  the  rock  of  faith  to  which  the 
sandy  or  gritty  (courageous)  soul  may  cling  until  his 
sands  run  out,  his  position  preventing  even  the  small 
legacy  of  a  "footprint  in  the  sands  of  time." 

One  discountenances  a  wrong  by  making  a  wry  face. 
There  is  an  injunction  to  purge  your  conscience  of 
dead  works.  One  in  contempt  of  court  may  be  purged 
of  this  contempt  if  satisfactory  explanation  is  forth- 
coming. In  death  the  silver  cord  (spinal)  is  loosed, 
the  golden  bowl  (skull  and  contents)  is  broken,  the 
pitcher  (heart)  is  broken  at  the  fountain,  and  the 
wheel  (kidneys)  at  the  cistern. 

There  are  native  and  foreign  tongues,  the  tongue  of 
land,  and  tongues  of  fire  that  lap  up  the  inflammable. 
A  likeness  may  be  speaking.  There  are  the  flood  of 
criticism,  the  brown  study,  the  breath  of  suspicion. 


SYMBOLISM   IN   SANITY  AND  IN   INSANITY.  55 

A  certain  white  fur  is  the  symbol  of  purity,  because 
of  the  dainty  habits  of  the  ermine;  the  stork  symbol- 
izes piety  and  thankfulness ;  acacia,  cypress,  and  cedar 
durability  (immortality),  for  their  qualities  of  resist- 
ance to  the  ravages  of  decay  and  insects.  The  palm 
suggests  triumph,  because  of  its  elasticity  and  power 
of  resistance.  Tears  are  pearls  ("Perlen  bedeuten 
Thranen"). 

Events  never  happened  thirty-nine  or  forty-five 
years  ago,  but  to  the  reminiscent  invariably  occurred 
forty  years  ago.  It  would  be  interesting  to  discover 
how  far  the  assignment  of  this  number  was  deter- 
mined by  Scriptural  incidents,  the  forty  days  and 
nights'  deluge,  the  forty  years  in  the  wilderness,  the 
fast  of  forty  days.  Was  the  expression  "three  times 
and  out"  determined  by  the  crow  of  the  cock  accom- 
panying Peter's  denial  of  Christ,  and  is  the  notorious 
partiality  for  the  use  of  the  number  three  occasioned  by 
the  period  of  Christ's  interment  before  the  resurrec- 
tion, and  by  the  Trinity  concept?  One  can  hardly 
escape  looking  for  the  third  accident  or  misadventure 
in  the  presence  of  two  preceding.  The  tragic  incidents 
succeeding  the  last  supper  prevent  the  meticulous 
housewife  from  seating  thirteen  at  table. 

To  that  portion  of  the  anatomy  upon  which  the  body 
rests  in  sitting  has  been  vulgarly  given  the  name  of  a 
domestic  animal,  a  burden  bearer.  The  subtle  asso- 
ciation connected  with  this  word  was  the  cause  of 
much  trepidation  on  the  part  of  a,  minister  of  my  ac- 
quaintance. He  felt  himself  constantly  in  danger  in 
reading  the  tenth  commandment  of  conveying  to  his 
auditors  the  injunction  not  to  covet  his  neighbor's  "Ax 
nor  his  oss."  Once,  indeed,  the  mistake  was  made,  as 


56  SYMBOLISM    IN   SANITY  AND  IN   INSANITY. 

under  the  bewildering  conditions  was  inevitable. 
Another  friend  avoided,  where  possible,  pronouncing 
the  name  of  a  certain  outdoor  game  because  of  an  im- 
polite substitution  for  the  true  name,  implanted  in  his 
boyish  mind  many  years  before. 

The  plant  and  animal  kingdoms  furnish  numerous 
examples  of  symbolism.  There  is  a  Trinity  (three 
organs)  represented  by  the  clematis.  The  poppy  signi- 
fies the  immature  product  of  conception.  Reference 
to  the  menstrual  flow  is  made  by  the  use  of  the  word 
flowers.  Apples  constitute  a  well-known  symbol  for 
the  breasts,  which  are  also  known  as  bubbies  or 
brothers.  Owing  to  the  fact  that  they  furnish  the 
germinal  principle,  the  name  for  a  fruit  of  the  tree  is 
applied  vulgarly  to  the  contents  of  the  scrotal  sac. 
Because  of  the  shape  and  covering  of  certain  roots  and 
fruits  their  names  have  been  transferred  to  the  prin- 
cipal organ  of  generation  in  the  male.  Eggs  suggest 
the  fundamental  facts  of  life-continuance. 

Colors  are  lively  and  gay  or  somber.  White  is 
emblematic  of  chastity,  green  of  verdancy  or  jealousy 
(the  green-eyed  monster),  red  of  brightness  and 
optimism,  and  gray  of  the  reverse  of  these.  Red  also 
stands  for  anarchy.  Yellow  has  come  to  be  identified 
with  mental  debility  (jaundice,  cachexia,  and  that 
which  is  undesirable,  the  yellow  journal).  Brown 
symbolizes  certain  bodily  parts  and  functions.  There 
is  Scriptural  authority  for  "though  thy  sins  be  as 
scarlet."  Blue  is  the  tint  of  emotional  depression; 
cardinal  and  purple  point  to  authority,  ecclesiastical  or 
regal. 

The  Klang  association,  that  of  words  of  the  same 
sound  as  pronounced,  but  of  different  signification,  is 


SYMBOLISM   IN   SANITY  AND  IN   INSANITY.  57 

the  occasion  of  much  embarrassment  and  inconve- 
nience to  the  susceptible.  Take,  for  example,  through 
the  word  "bear,"  the  suggestion  of  a  burden  physical  or 
mental,  parturition,  a  wild  animal,  and,  because  of 
sound  association  through  "bare,"  that  of  nudity.  The 
word  "ball"  suggests  the  national  game,  the  tango,  a 
bearing  in  a  wheel,  its  unrelated  "bawl,"  the  cry  of  an 
infant,  and  milk  of  magnesia.  The  word  "grip"  sug- 
gests a  fraternal  order,  friendship,  poverty,  disease, 
and  death.  The  right  and  left  associations  are,  as 
everybody  knows,  among  the  most  common,  the  left 
implying  the  negative,  neglected,  and  insincere;  the 
right,  the  positive,  straightforward,  and  dependable. 
Such  associations  as  those  above  mentioned  are  uni- 
versal. They  insistently  obtrude  themselves  into 
thinking  like  Banquo's  ghost  at  the  table  of  Macbeth. 
In  health  they  are  for  the  most  part  ignored  and  are 
the  source  of  no  particular  discomfort.  In  mental  dis- 
ease, on  the  contrary,  they  become  the  bases  for  dis- 
tressing word  obsession. 

Dementia  prsecox,  the  paranoid,  hysteric,  and  hys- 
teroidal  states  furnish  the  best  examples  of  such  ob- 
session. A  suppressed  sexual  experience  in  early  life, 
the  complex  of  the  Freud  school,  not  rarely  supplies 
the  groundwork  for  painful,  provoking,  and  persistent 
mental  hammering  and  determines  morbid  conduct  in 
pronounced  degree.  Indecisions,  negativism,  and 
mutism  may  owe  their  origin  to  a  subtle  something 
below  the  plane  of  conscious  acting,  and  irritability 
and  verbal  castigation  of  other  people  are  in  certain 
cases  interpretable  as  self-censure  for  previous  trans- 
gressions. Emotions  inspired  by  the  imperfect  revela- 
tion to  the  patient  of  a  mental  cesspool  give  rise  to 


58  SYMBOLISM  IN  SANITY  AND  IN  INSANITY. 

religious  doubts  and  misgivings  and  to  the  delusion  of 
loss  of  soul.  "Salt"  with  which  one  was  obsessed  re- 
ferred to  this  article  used  on  the  finger-tips  for  the 
purpose  of  titillation  of  the  sexual  organs.  Another 
once  spoke  irritably  of  an  instrument  of  porcelain 
used  on  her  mother.  The  mother  proved  to  be  herself 
and  the  instrument  of  porcelain  her  own  finger  in- 
serted into  the  vagina.  The  symbol  of  the  serpent  is 
as  old  as  mythology.  A  black  snake  mentioned  by  one 
referred  to  the  person  of  a  brunette  male  acquaintance. 
The  delusion  of  fatherhood  in  an  unmarried  virgin  had 
its  origin  in  playful  contact  with  another  little  girl  in 
childhood.  Poppies  and  the  fig-leaf  are  mentioned  by 
those  whose  thoughts  frequently  revert  to  the  sexual 
apparatus.  Green  pastures  symbolize  to  one  that 
which  is  fed  upon  as  well  as  that  which  produces.  The 
"corner  of  Pine  Street  and  Broadway"  was  translated 
as  indicating  first  sexual  pining,  second  the  "broad 
way"  which  leadeth  to  destruction,  or  in  her  language 
"where  any  old  thing  might  happen."  The  color  green 
affronted  one  patient  because  of  the  intimation  of  lack 
of  worldly  wisdom.  A  command  to  lift  the  curtain 
meant  to  uncover  the  figure.  "Woman"  suggested  woo 
men.  One  was!  obsessed  by  the  colloquial  term  for 
breasts.  It  came  to  her  over  and  over  and  evidently 
originated  from  the  self-scrutiny  of  vanity  or  from  the 
less-comfortable  emotion  of  chagrin  because  of  ana- 
tomical imperfections.  The  word  "banana"  was  by 
one  divided  into  Anna  and  Nana  and  the  false  implica- 
tion followed  that  Nantucket  (took  it).  The  obsession 
of  the  word  "basket"  was  determined  by  the  contents 
of  a  work  basket  amongst  which  was  a  darning  ball, 
the  handle  of  which  had  been  used  within  the  vagina. 


SYMBOLISM   IN   SANITY  AND  IN   INSANITY.  59 

A  skirt  hanging  on  a  banister  conveyed  an  invitation  to 
go  up  (stairs).  Blackberries  may  be  avoided  because 
seedy ;  spoons  upon  the  table  are  looked  upon  as  a  re- 
flection. The  word  "Jackson"  encountered  in  reading 
calls  out  the  irritable  assertion  that  there  was  never  any 
Jack  or  any  son.  .Reds  and  browns  symbolize  the 
pelvic  organs  and  certain  bodily  functions;  green,  the 
apron  of  Adam  and  Eve.  It  is  a  safe  color  because  of 
the  experiences  in  the  Garden  of  Eden.  Prunes  sug- 
gest prudery.  (Prunes  and  Prisms.) 

Certain,  drawings  and  art  productions  of  the  insane 
display  occult  associations  of  symbolic  significance. 
Question  of  a  patient.  Isn't  that  a  beautiful  head  ? 
Ans.  Yes.  Q.  From  what  did  you  copy  it?  Ans. 
The  temptation  of  St.  Anthony.  Q.  What  does  the 
clover-like  drawing  signify?  A.  The  Trinity.  Q. 
Anything  else?  A.  I  don't  know,  trailing  arbutus, 
hepatica.  It  has  fuzz  on  the  stem.  Q.  Of  what  is  it 
all  symbolic?  A.  Nothing.  Oh,  that  dreadful  sym- 
bolism. Q.  What  does  the  particular  drawing  sig- 
nify? A.  An  ellipse,  a  something  to  be  desired.  (At 
the  same  time  making  a  tracing.)  Q.  In  its  entirety 
it  is  a  sexual  symbol,  is  it  not?  A.  I  don't  know — 
very  likely — perhaps  it  was — they  were  there  together. 
(St.  Anthony  and  the  temptress?) 

One  wrote :  "The  feathery  clematis  is  to  me  as  the 
fluffy  winter  girl.  To  study  you  what  a  trinity  each 
branch,  each  terminus,  holds  to  me,  plumed  seed,  a 
thought,  an  emblem  of  Free  Masonry."  The  fluffiness 
referred  to  a  peculiarity  of  the  clematis  blossom; 
trinity,  to  the  three-branch  division  of  the  blossom; 
feathery  and  plumed,  to  the  chapeau  of  a  Knight 
Templar  in  whom  she  had  been  interested. 


60  SYMBOLISM   IN   SANITY  AND  IN   INSANITY. 

Maeterlinck's  Jocelyn  suggested  to  one  The  Copley 
Society,  Copley  in  turn  calling  up  "Home,  family." 
It  goes  way  back  to  Genesis:  "Be  fruitful  and 
multiply." 

The  obsession  "pig,  pig,"  was  determined  in  the  case 
of  one  by  the  recollection  of  an  erotic  relation  between 
herself  and  a  summer  boarder  of  the  opposite  sex. 
They  had  been  sufficiently  intimate  for  him  to  permit 
himself  to  name  her  breasts  and  he  had  placed  his 
hand  on  different  parts  of  her  body.  Once  he  ap- 
peared before  a  company  carrying  a  young  pig.  With 
the  subsidence  of  the  sexual  interest  this  symbolized 
in  her  mind  that  which  is  dirty  and  fleshly. 

A  patient  was  insulted  because  mention  was  made 
to  her  of  the  theater  opening  night  and  because  a  man 
friend  had  invited  her  to  visit  the  monkey  house  at  the 
zoo.  The  color  red  was  extremely  objectionable  to 
one  patient  because  of  some  occult  association.  This 
could  never  be  definitely  brought  to  light,  but  it  is  con- 
jectured it  has  to  do  with  the  menstrual  flow,  and  to 
childish  impressions  thereto  related.  Another  had  a 
prejudice  against  trees,  because  they  suggested  the 
woods  from  which  she  felt  she  must  emerge.  The 
figure  of  an  owl  perched  in  the  middle  of  an  oval  belt 
buckle  symbolized  to  the  artist  "wisdom  in  eugenics" 
or  scientific,  intelligently  directed,  perhaps  artificial 
impregnation. 

It  is  not  difficult  to  understand  in  the  light  of  all  this 
how  morbid  thinking  is  promoted  through  fleeting  im- 
pressions obtained  from  without,  through  touch,  taste, 
hearing,  sight,  and  smell.  What  is  read  is  miscon- 
strued and  given  personal  application.  Attitudes  are 
misunderstood;  the  meaning  of  words  is  perverted, 


SYMBOLISM    IN   SANITY  AND  IN   INSANITY.  61 

and  there  is  distortion  of  the  most  commonplace  ex- 
periences of  everyday  life. 

If  it  is  possible  to  uncover  the  complex  from  which 
a  word  obsession  originates  it  is  often  extremely  help- 
ful to  the  patient  to  do  this.  Brought  to  light,  its  im- 
portance may  be  minimized,  its  in  most  cases  utter  in- 
significance emphasized.  Many  are  greatly  relieved  to 
know  that  they  are  not  alone  in  harboring  symbols  of 
an  erotic  and  questionable  character,  and  that  in  under- 
lying motives,  reactions  to  environment  and  response 
to  the  incidents  of  earlier  years,  there  is  much  that  all 
the  world  has  in  common  and  recalls  with  chagrin ;  but 
that  to  attempt  to  suppress  recollection  is  futile,  and  to. 
indulge  in  self-castigation  utterly  inexpedient. 


PART  III. 


INSANITY. 

INSANITY  is  defined  as  ''a  prolonged  departure  from 
the  individual's  normal  standard  of  thinking,  feeling, 
and  acting"* 

It  is  a  prolonged  departure,  because  there  are  many 
.conditions  in  which  there  are  temporary  departures 
from  the  normal  standard  of  thinking,  feeling,  and  act- 
ing which  are  not  called  insanity.  Thus,  in  intoxica- 
tion one  neither  thinks,  feels,  nor  acts  as  when  sober, 
but  this  is  not  accounted  an  insane  condition,  and  the 
subject  is  fully  responsible  in  the  eyes  of  the  law  for 
his  conduct.  It  is  true  of  shock,  a  blow  on  the  head, 
fright,  an  epileptic  convulsion,  fainting  (from  loss  of 
blood  or  heart-failure),  and  apoplexy,  that  there  may 
be  temporary  loss  of  consciousness  and  the  mind  does 
not  act  naturally ;  but  the  person  thus  suffering  is  not 
regarded  insane.  Insanity  may  develop  in  consequence 
of  injury,  in  consequence  of  the  loss  of  blood,  and  in 
consequence  of  apoplexy  or  epilepsy;  but  the  insane 
condition  is  here  secondary  and  due  to  accompany- 

1  All  definitions  of  insanity  must  be  more  or  less  arbitrary, 
inadequate,  and  open  to  objection,  but  this,  the  simplest  one 
with  which  I  am  familiar,  designates  tolerably  well  those  con- 
ditions of  mental  aberration  with  which  alienists  have  chiefly 
to  deal,  and  will  for  working  purposes  ordinarily  be  found 
sufficient. 
(62) 


INSANITY.  63 

ing  change  in  nutrition  of  the  brain  or  damage  to  its 
structure.1 

The  definition  speaks  of  the  individual's  normal 
standard.  This  means  that  every  case  is  a  law  unto 
itself :  that  there  is  no  fixed  standard  of  thinking,  feel- 
ing, and  acting.  It  cannot  be  said,  for  example,  because 
one  does  not  act  under  certain  conditions  as  his  neigh- 
bor acts,  because  he  does  not  show  the  same  amount 
of  feeling  that  his  neighbor  manifests,  or  because  he 
does  not  think  in  the  same  lines  that  his  neighbor 
thinks,  that  he  is  insane  and  the  other  sane.  In  giving 
an  opinion' as  to  whether  insanity  exists,  it  is  necessary 
to  compare  the  person's  present  with  his  former  habits 
of  thinking,  feeling,  and  acting. 

The  "departure"  may  display  itself  in  complete 
change  of  characteristics,  tastes,  and  tendencies:  in 
simple  perversions  of  the  feelings  and  judgments;  or 
in  an  exaggeration  of  natural  traits  of  character. 

Causes  of  Insanity. 

These  are  as  numerous  as  the  causes  of  disease  in 
general.  They  may  be  classified,  for  convenience,  ap- 
proximately as  follows : — 

Direct  physical  causes,  36  per  cent. 

Indirect  physical  and  emotional  causes,  8  per  cent. 

Vicious  habits,  25  per  cent. 

Constitutional  and  evolutional  causes,  28  per  cent. 

1.  Direct  Physical  Causes. — These  are  such  as  affect 
mental  operations  through  direct  action  upon  the  brain : 
a  blow  on  the  head;  injury;  hemorrhage;  disease  of 


1  The  word  "insanity"  means  literally  "unsoundness,"  but  it 
is  the  medical,  not  the  literal,  meaning  which  is  here  given. 


64  INSANITY. 

any  kind,  as  cancer,  consumption,  Bright's  disease; 
childbearing  and  its  attendant  perils;  prolonged  nurs- 
ing, etc.  In  each  of  these  there  is  a  direct  action  upon 
the  brain,  either  from  violence,  through  increase  or 
diminution  of  its  blood-supply,  through  deleterious 
substances  carried  in  the  blood,  or  through  altered 
nervous  sensations  going  from  the  part  affected  to  the 
brain. 

2.  Indirect  Physical  and  Emotional  Causes. — Under 
this  head  are  grouped:  fright;  shock  (not  shock  from 
surgical  operation  or  bodily  injury,  but  from  sudden 
terrific  strain  upon  the  emotions);  grief;  care  and 
anxiety;  business  failure;  trouble  of  various  kinds; 
domestic  infelicity;  disappointed  affections;  the  feign- 
ing of  insanity;  companionship  with  those  who  are 
morbid;  imitation.  Causes  such  as  these  affect  the 
brain  indirectly  through  the  physical  system.  For 
example,  the  man  who  has  failed  in  business,  loses 
sleep ;  he  does  not  take  the  proper  amount  of  exercise, 
perhaps  through  fear  of  meeting  acquaintances  and 
having  his  troubles  brought  vividly  before  his  mind; 
his  appetite  is  impaired — he  takes  food  indifferently  or 
refuses  it  altogether.  He  has  actual  distaste  for  food — 
this  because  his  changed  habits  of  life  have  brought 
about  disorder  with  the  emunctories  of  the  system — 
the  bowels,  kidneys,  skin,  and  lungs.  What  food  he 
takes  is  imperfectly  digested  and  badly  assimilated. 
The  blood-supply  to  the  brain  is  insufficient  and  im- 
poverished in  quality.  Sleep  is  troubled  by  painful 
dreams,  it  does  not  rest  him,  and  the  process  of  repair 
which  constantly  goes  on  in  the  brain  during  sleep  in 
the  normal  state  is  not  carried  on  naturally  during  the 
period  of  emotional  strain.  Eventually,  through  all 


INSANITY.  65 

these  causes,  he  loses  his  ability  to  think,  to  feel,  to  act 
naturally ;  and  there  comes  to  be  a  prolonged  departure 
from  his  normal  standard  in  these  respects,  constitut- 
ing insanity. 

3.  Vicious  Habits. — Under  this  head  are  classed: 
intemperance;  opium,  chloral,  and  cocaine  addiction; 
sexual  excess;  self-abuse;  and  all  habits  of  life  which 
directly  undermine  the  physical  constitution  and  thus 
affect  the  brain.1 

4.  Constitutional   and  Evolutional   Causes. — Under 
this  head  come  all  causes  of  insanity  which  operate  be- 
cause of  some  innate  defect  in  constitution  or  develop- 
ment  of   the   individual.      Here   hereditary   tendency 
figures  to  a  great  extent.    One  inherits  a  susceptibility, 
so  called,  to  mental  disease  from  intemperate,  vicious, 
insane,  or  delicate  ancestors.    His  nervous  constitution 
is  unequal  to  the  task  of  carrying  him  through  certain 
inevitable    crises    in    development.      There    is   known 
hereditary  tendency  to  mental  diseases,  either  remote 
or  immediate,  in  about  50  per  cent,  of  all  cases  under 
treatment  in  large  institutions.     Probably  if  the  facts 
were  invariably  discoverable,  the  percentage  would  be 
found  vastly  greater. 

Among  the  constitutional  and  evolutional  causes  are 
Pubescence. — The  pubescent  period  is  that  during 
which  the  boy  or  girl  passes  to  manhood  or  woman- 
hood. At  this  period  the  organs  of  reproduction  take 
on  development  and  a  change  in  characteristics  and 
personality  occurs.  Certain  desires,  aspirations,  and 
tendencies  not  before  felt  are  then  first  experienced. 

1  It  will  be  observed  that  vicious  habits  are,  after  all,  but 
direct  causes;  but  for  convenience  and  clearness  they  are 
separately  considered. 


66  INSANITY. 

It  is  a  critical  time  in  the  life  of  the  individual,  and 
unless  he  or  she  is  well  organized,  mental  overthrow  is 
apt  to  occur.  One  of  the  forms  of  manic-depressive 
insanity  (the  recurrent)  frequently  develops  at  this 
stage  of  life.  The  age  at  which  pubescence  is  estab- 
lished varies  in  different  climates.  For  this  climate  it 
is  approximately  from  13  to  15  years. 

Adolescence. — Possibly  the  individual  may  have 
passed  safely  the  pubescent  period,  having  inherited 
sufficient  nervous  strength  to  carry  him  beyond  this 
first  physiological  crisis,  but  at  the  next  developmental 
period  (that  of  adolescence)  he  breaks  down,  without 
direct  assignable  cause,  or  from  some  cause  which 
would  be  insufficient  to  produce  insanity  in  one  well 
constituted.  The  adolescent  period  comes  at  the  age 
of  25  to  35. 

Again :  The  mile-stones  Pubescence  and  Adolescence 
may  be  left  behind  in  the  march  of  development,  and 
the  person  go  on  mentally  well  until  the  change  of 
life, — the  so-known  Climacteric  Period.  This  change 
in  the  woman  takes  place  at  the  age  of  about  45 ;  in 
the  man,  between  50  and  60.  It  marks  in  both  a  sta- 
tionary plane.  The  period  of  development  is  past,  and 
those  organs  which  took  on  activity  at  the  time  of  the 
pubescent  epoch  begin  to  cease  active  functionating. 

About  fifteen  years  later — in  the  woman  of  60  and 
the  man  of  70 — Senile  changes  (those  due  to  old  age)1 
make  their  appearance,  and  mental  and  bodily  feeble- 
ness ensues.  Frequently  mental  enfeeblement  reaches 
such  an  extreme  that  insanity  is  said  to  exist. 

1  Every  person  has  his  limitations  and  possibilities,  and 
earlier  senility  may  occur  if  one's  nervous  and  mental  energy 
has  not  been  conserved  and  if  the  output  has  been  excessive. 


INSANITY.  67 

We  have  thus  the  four  periods :  Pubescence,  mark- 
ing the  advance  from  youth  to  manhood;  Adolescence, 
that  from  manhood  to  maturity  (these  two  periods  are 
developmental  or  evolutional)  ;  Climacteric,  the  sta- 
tionary period ;  and  Senile,  the  dissolutional  period,  or 
period  of  decay. 

Causes  of  insanity  may  be  conveniently  grouped 
under  one  of  the  four  heads  above  mentioned.  In 
every  case  the  natural  constitution  of  the  subject 
figures  to  a  greater  or  less  extent.  It  is  true  of  the 
direct  and  indirect  physical  causes,  as  well  as  of 
vicious  habits,  that  a  cause  feeble  in  its  intensity  may 
produce  a  disturbance  of  balance  in  one  not  well 
organized,  whereas  one  having  a  good  nervous  inheri- 
tance and  strong  mental  equipment  may  be  able  to 
resist  the  cause  and  retain  his  integrity  of  mind. 

Forms  of  Insanity. 

There  is  no  such  thing,  strictly  speaking,  as  a  dis- 
ease of  the  mind ;  but  the  expression  is  commonly 
employed,  and  is  a  convenient  one  for  describing  dis- 
turbances of  those  operations  of  the  brain  which  in- 
volve consciousness.  Mental  disease  is  always  asso- 
ciated with  disturbance  of  function  or  structure  of  the 
brain.  Among  the  pathological  conditions  are  conges- 
tions, effusions,  anaemia  (lack  of  blood-supply),  opaci- 
ties of  the  membranes,  thinning  of  the  gray  matter, 
adhesions  of  the  membranes  to  the  cortex  of  the  brain, 
and  degeneration  of  brain  matter. 

The  names  commonly  employed  in  the  classification 
of  mental  disease  chiefly  stand  for  groups  of  symp- 
toms: Mania  being  a  Greek  word,  meaning  furor; 


68  INSANITY. 

Dementia  being  derived  from  two  Latin  words:  de, 
without,  and  mens,  the  mind;  Paranoia,  from  Greek 
words  para,  defective,  and  nous,  understanding.  One 
notable  exception  is  in  the  name  Melancholia,  which 
comes  from  two  Greek  words  meaning  "black  bile,"  it 
being  supposed  by  the  ancients  that  this  affection  was 
incident  to  disorder  of  the  liver. 

The  classification  of  insanity  and  the  study  of  in- 
sane conditions  have  undergone  modifications  almost 
revolutionary  in  very  recent  years.  The  former  divi- 
sion of  insane  conditions  into  States  of  Mental  Elation, 
States  of  Mental  Depression,  and  Structural  Brain 
Disease  with  Prominent  Mental  Manifestations,  is 
generally  regarded  as  inadequate  for  clinical  study. 
The  so-called  states  of  mental  elation  and  states  of 
mental  depression  are  now  considered  under  the  head 
of  manic-depressive  insanity,  the  terms  mania,  hypo- 
mania,  delirious  mania,  etc.,  being  employed  to  indi- 
cate the  symptoms  in  existence  during  the  excited 
periods ;  "depressive  states"  and  "apathetic  states" 
being  used  to  designate  the  condition  in  depressed 
periods  heretofore  described  as  melancholia,  and  the 
term  melancholia  limited  in  its  application  to  mental 
depression  occurring  in  the  senile  or  presenile  period 
of  life.  Terminal  dementia  and  dementia  following 
acute  forms  heretofore  designated  as  chronic  de- 
mentia, dementia  after  mania,  and  dementia  after  mel- 
ancholia are  no  longer  admitted  as  entities  in  classifica- 
tion, those  cases  of  insanity  heretofore  studied  under 
the  latter  heads  being  relegated  to  other  groups.  This 
reformation  in  classification  has  been  due  to  the  recog- 
nition of  a  state  underlying  the  morbid  nervous  proc- 
esses of  which  so-called  mania,  melancholia  and 


INSANITY.  69 

dementia  are  the  expression,  namely,  the  neuropathic 
organization.  Under  the  old  classification  embarrass- 
ment was  frequently  encountered  in  clinical  study  be- 
cause of  the  mixed  manifestations  in  the  so-called 
acute  forms  of  disease,  the  maniacal  patient  being 
rarely  consistently  maniacal  and  showing  an  exalted 
state  of  the  emotions,  the  depressed  patient  displaying 
from  time  to  time  fluctuations  in  the  emotional  states 
to  an  extent  incompatible  with  the  grouping  of  symp- 
toms under  states  of  emotional  depression.  Further, 
the  so-called  recurrent  mania  (folie  circulaire)  pre- 
sented the  picture  of  alternating  states  of  elation  and 
depression  with  or  without  intervals  of  lucidity,  the 
pendulum  at  one  time  swinging  over  to  lowered  emo- 
tional tone,  then  to  the  other  extreme.  These  clinical 
facts  led  to  the  study  of  the  manic-depressive  insani- 
ties under  the  one  head,  and  the  essential  unity  of  so- 
called  mania  and  melancholia  is  now  generally  recog- 
nized. Simultaneously  with  the  disappearance  of  these 
forms  of  disease  as  clinical  entities,  there  was  brought 
forth  a  name  under  which  is  included  certain  condi- 
tions of  psychical  degeneration  displaying  by  turns  the 
symptoms  of  mania  and  melancholia,  of  stupor  and  of 
dementia.  Its  existence  is  regarded  as  marking  psychi- 
cal degeneration  from  the  beginning.  It  is  the  so- 
called  dementia  prsecox.  As  in  the  preceding  edition 
of  this  book,  an  attempt  will  be  made  to  present  the 
essentials  of  the  classification  of  Kraepelin  so  far  as 
seems  expedient,  the  psychological -analysis  of  symp- 
toms heretofore  found  useful  for  purposes  of  study" 
being  retained  as  far  as  possible.  For  obvious  reasons 
it  is  impracticable  in  an  elementary  book  of  this  char- 
acter to  consider  fully  the  pathological  groundwork  of 
insane  conditions. 


70  INSANITY. 

Infection  Psychoses.1 

Under  the  infection  psychoses  are  included  the  delir- 
ium of  fever,  the  delirium  directly  due  to  infection, 
and  the  morbid  mental  states  following  fever.  These 
conditions  are  attributable  to  the  immediate  or  remote 
effects  of  the  toxins  or  poisons  of  infectious  diseases. 

The  phenomena  of  FEVER  DELIRIUM  are  familiar. 
Coincidently  with  the  occurrence  of  fever  there  are 
developed  flightiness  of  conduct,  dream  states,  hallu- 
cinations, wandering  speech,  and  increased  sensitive- 
ness to  touch,  to  sound,  and  to  sight,  depending  upon 
the  grade  of  fever  and  the  nervous  constitution  of 
the  individual.  Certain  children  invariably  display 
delirium  in  the  progress  of  any  febrile  disorder.  In- 
deed, in  some,  illness,  however  slight,  is  accompanied 
by  head  symptoms.  The  simple  digestive  derange- 
ments, the  eruptive  diseases,  and  the  cutting  of  teeth 
are  attended  by  temperature  and  delirium. 

The  grade  of  delirium  as  a  rule  corresponds  to  the 
degree  of  temperature,  to  the  activity  of  the  poison 
which  gives  rise  to  the  fever,  to  the  rapidity  of  tissue 
change,  to*  the  extent  to  which  the  circulation  is  dis- 
turbed, and  to  the  previous  habits  of  the  individual, 
particularly  as  to  alcoholic  indulgence.  In  the  severe 
grades  the  movements  of  the  patient  are  purposeless, 
there  are  complete  incoherence  and  unconsciousness 
of  surroundings.  There  may  be  obliteration  of  per- 
.ception  and  consciousness,  with  apparent  wakefulness 

1  Psychosis  (plural,  psychoses)  signifies  any  form  of  mental 
derangement,  more  particularly  where  there  is  no  discernible 
pathological  condition  in  the  brain  to  account  for  the  de- 
partures from  the  normal. 


INSANITY.  71 

and  staring  eyes,  the  so-called  coma  vigil.  Inconti- 
nence of  urine  and  lack  of  control  of  the  bowels  are 
present.  The  delirium  may  subside  with  the  fever 
and  consciousness  become  clear,  or  the  morbid  impres- 
sions developed  during  delirium  may  continue  after  its 
subsidence. 

Delirium  accompanying  pneumonia  has  in  my  ex- 
perience led  to  the  unwise  removal  of  a  patient  from 
her  home  to  a  hospital  for  the  insane.  This  disease 
occurring  in  an  habitual  drinker  is  prone  to  give  rise 
to  hallucinatory  impressions  colored  largely  as  are 
those  of  pure  alcoholic  delirium. 

States  of  profound  hebetude  and  torpor  attend  upon 
certain  forms  of  influenza.  There  are  emotional  de- 
pression, dullness,  and  indisposition  to  exertion,  and, 
after  the  subsidence  of  fever,  enduring  lassitude,  per- 
haps going  over  into  neurasthenia.  In  one  instance, 
indeed,  epilepsy  owed  its  origin  in  a  previously  vigor- 
ous man  to  an  attack  of  la  grippe. 

The  delirium  of  typhoid  fever  is  not,  as  a  rule,  of 
an  active  character.  Muttering,  picking  at  the  bed- 
clothes, tremulous  movements,  startings,  and  twitch- 
ings  are  present,  but  no  pronounced  muscular  activity. 
Occasionally,  however,  intense  hallucinatory  or  illu- 
sional  impressions  and  the  fear  of  injury  impel  the 
feeble  patient  to  rise  from  bed,  cause  him  to  make 
determined  resistance  to  his  nurses,  and  lead  to  death 
from  precipitation  from  the  window  or  stairway. 

In  INFECTION  DELIRIUM,  that  is  to  say,  that  form 
directly  due  to  the  septic  poison  of  the  disease,  there  is 
no  definite  relation  to  temperature.  There  are  delu- 
sions of  persecution,  the  emotions  are  depressed,  and 
visual  and  auditory  hallucinations  occur.  Confusion 


72  INSANITY. 

of  ideas,  and  extreme  restlessness  and  incoherence  are 
present  in  some  cases.  Diefendorf  (Kraepelin)  says 
that  in  small-pox  during  the  formation  of  pustules 
between  the  eruption  and  pus  fever,  there  is  a  charac- 
teristic mental  disturbance  which  seems  due  to  infec- 
tion. The  grade  of  delirium  of  typhoid  fever  varies 
according  to  the  severity  of  the  physical  symptoms. 
That  it  is  not  the  prolonged  temperature  alone  that 
determines  the  delirious  state,  but  actual  damage  done 
to  the  brain  by  the  circulation  in  the  blood  of  a  poison- 
ous principle,  is  considered  probable  because  of  the 
frequent  apparently  causative  relation  of  the  typhoid 
to  subsequent  and  often  permanent  mental  impair- 
ment (dementia  prsecox). 

Facial  erysipelas  is  frequently  accompanied  by  de- 
lirium. Rheumatism,  endocarditis,  and  chorea,  all  re- 
lated diseases,  may  be  attended  with  grave  confusional 
and  hallucinatory  manifestations.  Delirium  occurs  in 
hydrophobia  and  terminates  in  fatal  collapse. 

In  POST-FEBRILE  conditions  there  are  often  inepti- 
tude, lethargy,  incapacity  for  concentrating  the  atten- 
tion, delusions,  and  indifference.  The  germ  of  insanity 
may  find  itself  in  the  delirium  developed  during  the 
progress  of  fever,  or  the  mental  disturbance  may  come 
on  after  the  subsidence  of  temperature.  Patients  be- 
come irritable  and  depressed,  hallucinations  are  occa- 
sionally in  evidence,  and  in  some  cases  delusions  of 
distrust  and  persecution  appear.  Dangerous  impulses 
may  be  present.  In  the  most  severe  cases,  delusions  of 
persecution  are  well  marked.  There  is  complete  in- 
coherence, the  speech  is  confused,  suspiciousness  is 
present,  and  there  are  delusions  of  unseen  agency  and 
poison. 


INSANITY.  73 

Hystero-maniacal  and  manic-depressive  states,  at- 
tended with  strong  antipathies  toward  relatives  and 
those  in  the  immediate  care  of  the  patient,  occasionally 
develop  in  consequence  of  some  of  the  fevers,  notably 
thq  rheumatic.  Fevers  may  also  be  the  starting  point 
or  determining  cause  of  a  subsequent  dementia  prsecox. 
The  physical  state  is  undermined  by  the  rheumatic  con- 
dition, and  the  cardiac  and  other  evils  attendant  upon 
it.  The  young  patient  in  consequence  of  the  condition 
of  invalidism  is  indulged  and  the  will-power  and  self- 
control  remain  undeveloped.  Patients  grow  impulsive, 
irritable,  fretful,  inconsiderate,  and  are  subject  to  emo- 
tional storms. 

Under  the  head  Post-febrile  Infection  Psychoses,  a 
SIMPLE  NEURITIS  has  been  described,  the  characteristics 
of  which  are  feeble  memory,  failure  of  attention,  and 
a  disposition  to  fabricate.  The  symptoms  may  be  dif- 
ferentiated from  those  of  paretic  dementia  by  the  ab- 
sence of  pupillary  phenomena,  disturbance  of  speech, 
and  other  motor  indications  of  the  latter  disease. 

Treatment. — The  treatment  of  febrile  delirium  and 
infection  delirium  should  be  largely  directed  to  the 
physical  symptoms.  Elimination  by  the  skin,  by  the 
kidneys,  and  by  the  bowels  should  be  favored.  The 
high  flushing  of  the  bowels  is  especially  valuable.  The 
ice-cap  to  the  head,  cool  sponging  to  reduce  tempera- 
ture, and  the  use  of  remedies,  strychnine,  caffeine,  and 
quinine,  to  support  the  heart's  action,  are  valuable.  In 
cases  where  it  is  impossible  to  induce  the  patient  to 
take  sufficient  liquid  nourishment  by  the  mouth,  re- 
course should  be  had  to  rectal  alimentation — the  giving 
of  nutritive  enemata,  of  water  or  of  the  normal  salt 
solution,  by  the  bowel.  In  all  delirious  conditions  it  is 


74  INSANITY. 

necessary  that  the  patient  be  given  watchful  attention 
owing  to  the  danger  of  self -in  jury.  Mechanical  re- 
straint, as  with  the  rest  sheet,  is  sometimes  indis- 
pensable. 

The  treatment  of  the  post-febrile  psychoses  may  in- 
volve rest  in  bed  for  a  considerable  period  of  time. 
Attention  should  be  directed  to  building  up  the  general 
health.  Where  neuritis  is  an  element  in  the  psychosis, 
treatment  should  be  directed  to  that  condition.  Pa- 
tients with  well-marked  delusions  of  suspicion  in  re- 
spect to  their  environment  will  be  more  likely  to 
improve  under  hospital  conditions  than  at  home.  In 
cases  where  suspiciousness  is  so  strong  as  to  create  de- 
lusions of  poison,  tube-feeding  may  be  necessary.  A 
tonic  medicinal  regimen  is  indicated. 

Exhaustion  Psychoses. 

Under  this  head  are  grouped  insanities  due  to  ex- 
treme nervous  reduction.  They  are  of  sudden  onset 
and  pursue  a 'rapid  course  to  recovery,  or  terminate  in 
chronic  states  of  nervous  exhaustion.  The  exciting 
causes  are  childbirth,  prolonged  lactation,  excessive 
mental  strain  and  shock,  intense  care  and  anxiety, 
fractures,  particularly  where  there  is  the  complication 
of  precedent  alcoholic  over-indulgence. 

COLLAPSE  DELIRIUM. — Collapse  delirium  develops 
rapidly  after  a  condition  of  sleeplessness.  There  are 
confusion  of  thought,  restlessness,  and  excitement. 
There  are  incoherency  and  delusions  of  persecution  and 
unseen  agency.  Threatening  voices  are  heard  which 
impel  the  patient  to  impulsive  acts,  to  jump  from  bed, 
to  run  about  the  room,  and  perhaps  to  precipitate  her- 
self from  the  window. 


INSANITY.  75 

A  young  woman,  the  mother  of  two  children,  both  living, 
whose  health  was  good  until  marriage,  broke  down  five  years 
thereafter.  There  were  delusions  of  apprehension  and  various 
auditory  hallucinations  of  a  painful  character.  A  certain 
degree  of  mental  and  considerable  physical  betterment  fol- 
lowed the  removal  of  degenerated  ovaries.  She  had  fears 
that  she  was  to  be  killed,  and  that  her  family  and  property 
were  in  danger.  She  refused  food,  omitted  to  empty  the 
bladder,  feared  poison.  There  was  negativism.  Once  after  a 
hard  struggle  vainly  made  to  catheterize,  she  turned  to  the 
nurse  and  said:  "Now  you  may  pass  the  catheter."  She  did 
sudden  acts  of  violence,  but  had  periods  of  self-control  during 
which  she  conversed  pleasantly  on  the  subject  of  music. 
After  the  visit  of  a  consulting  physician  whom  she  had  not 
before  seen  she  expressed  the  delusion  that  he  had  hypnotized 
her.  This  case  furnished  an  excellent  example  of  stereotypy 
in  expression.  She  repeated  over  and  over  identical  sentences 
and  was  constantly  influenced  by  vivid  hallucinations  of  hear- 
ing that  her -property  had  been  stolen.  Improvement  occurred, 
then  relapse,  followed  by  physical  prostration,  complete  refusal 
of  food,  regurgitation  of  that  given  by  the  tube,  and  profound 
confusion.  Later  both  mental  and  physical  betterment  ap- 
peared, but  the  leading  mental  symptoms,  remaining  in 
evidence,  indicate  that  the  original  collapse  delirium  was 
the  initial  period  of  a  dementia  praecox. 

Another  patient  suffering  from  collapse  delirium 
also  displayed  stereotypy,  repeating  over  and  over 

"Tom here's  your  wife."    In  this  form  of  disease 

there  may  be  eroticism,  extreme  untidiness,  and  ex- 
posure of  person.  Such  patients  resist  attention.  The 
duration  of  collapse  delirium  is  usually  short  and  the 
first  mental  illumination  appears  suddenly.  Convales- 
cence, once  established,  may  go  on  rapidly  or  slowly  in 
proportion  to  the  amount  of  reduction  the  physical 
forces  have  sustained.  The  prognosis  is  favorable  if 
the  patient  can  be  safeguarded  from  injury  due  to  im- 
pulsive acts. 


76  INSANITY. 

ACUTE  CONFUSIONAL  INSANITY. — This  condition  is 
of  sudden  origin  following  exhaustive  illness.  There 
may  be  periods  of  unconsciousness  preceded  and  fol- 
lowed by  insomnia.  Delusions  of  fear  are  present. 
The  patient  believes  himself  persecuted  by  those  of 
other  religious  sects,  impugns  motives,  asserts  that  his 
property  is  to  be  destroyed.  Intermittent  delusions  of 
an  exalted  character  may  also  be  present.  The  patient 
is  restless  and,  although  weak  and  more  or  less  help- 
less, is  apt  to  be  up  and  about.  He  fancies  that  others 
are  trying  to  work  some  scheme  to  obtain  money,  has 
hallucinations  of  sight,  mistakes  figures  in  the  carpet 
for  animals.  Other  hallucinations  of  the  special  senses 
may  be  present.  There  is  disturbance  of  the  tempera- 
ture sense.  One  patient  that  I  knew  believed  that  snow 
was  falling  in  his  room.  There  are  extreme  mental 
confusion  and  a  tendency  to  impulsive  and  violent  acts. 
There  are  variations  in  the  emotional  sphere,  pleasur- 
able concepts  alternating  with  those  of  a  depressing 
character.  There  are  apt  to  be  deranged  secretion,  foul 
breath,  and  slight  elevation  of  temperature.  Suicidal 
attempts  in  frenzied  states  are  not  rare. 

A  woman  of  rather  frail  physique,  a  farmer's  wife  and 
extremely  industrious,  who  in  a  married  life  of  fifteen  years 
had  given  birth  to  four  children,  became  suddenly  depressed 
one  month  after  the  last  confinement.  This  took  place  hur- 
riedly and  delivery  was  instrumental,  but,  as  in  previous 
instances,  unattended  by  any  untoward  event  or  accident.  She 
took  part  as  spectator  in  a  revival  meeting,  but  was  not 
apparently  much  impressed  and  said  she  could  make  nothing 
out  of  it.  Later,  however,  she  began  to  talk  of  different  faults, 
that  she  had  not  told  the  truth,  that  she  had  been  dishonest 
in  not  looking  up  the  owner  of  fifteen  cents  found  as  many 
years  before.  She  took  food  sparingly  and  the  milk  supply 
ceased.  She  was  indifferent  to  the  removal  of  her  baby  to 


INSANITY.  77 

the  house  of  a  neighbor.  She  grew  resistive,  declined  to  wash 
her  hands,  would  not  permit  attention  from  others.  There 
were  brief  attacks  of  excitement,  during  which  she  ran  from 
her  room.  She  thought  the  devil  in  pursuit  and  expressed 
disbelief  in  God;  became  impressed  with  the  delusion  that 
her  surroundings  were  filthy,  talked  but  little,  and  this  in 
whining,  plaintive  tone.  There  was  great  mental  retardation. 
She  omitted  to  empty  the  bladder  except  on  suggestion  from 
her  husband,  feared  robbery,  was  repetitious;  asked  again 
and  again  if  this  is  her  room,  what  that  picture  is,  where  her 
husband  is,  what  it  all  means,  but  did  not  heed  replies.  She 
believed  herself  improperly  bathed,  that  the  toilet  room  was 
unfit  to  use,  that  food  served  was  not  such  as  furnished  to 
others.  She  was  terrified  when  taken  from  her  room  for  any 
reason  and  startled  by  noises,  as  of  a  distant  engine  whistle. 

Treatment. — In  the  treatment  of  the  acute,  exhaust- 
ive psychoses,  elimination  should  be  favored,  the  skin, 
bowels,  and  kidneys  being  kept  active.  Rest  in  bed  is 
imperative  and  forced  alimentation  may  be  necessary. 
'Owing  to  the  extreme  excitement  in  some  cases,  tube- 
feeding  may  be  from  time  to  time  demanded.  Cool 
sponging  and  the  alcohol  rub  are  valuable.  The  pro- 
longed bath  of  from  fifteen  to  twenty  minutes'  duration 
in  water  at  a  temperature  of  about  100°  is  serviceable 
in  some,  cases  where  there  is  no  resistance  to  this  form 
of  treatment.  During  the  bath  cold  cloths  should  be 
applied  to  the  head.  Rest  in  bed  with  the  ice-cap  to 
the  head  is  of  value  in  some  cases.  Medicines  to  sus- 
tain the  heart's  action,  either  hypodermically  or  by 
the  mouth,  are  useful.  In  giving  medicine  hypodermi- 
cally, care  should  be  taken  that  the  patient's  delusions 
are  not  intensified  by  this  method  of  administration. 
Where  hypnotics  are  necessary,  veronal  or  sulfonal  in 
5-  to  10-  grain  doses  may  be  employed.  If  chloral  is 
used,  strychnine  or  quinine  should  be  administered 


78  INSANITY. 

with  it  to  obviate  its  depressing  effects.  In  order  to 
prevent  further  exhaustion  and  collapse  and  to  permit 
the  application  of  cold  to  the  head,  the  rest  sheet  may 
be  required.  If  possible,  however,  restraint  should  be 
avoided. 

CHRONIC  NERVOUS  EXHAUSTION  (NEURASTHENIA). 
— This  condition  follows  shock,  excessive  mental  ap- 
plication, prolonged  mental  strain,  great  anxiety,  and 
sexual  excess.  In  connection  with  the  above  causes 
there  may  be  the  additional  factor  of  indulgence  in 
alcohol  taken  with  the  idea  of  temporary  relief  from 
depression. 

The  individual  is  conscious  of  inability  to  carry  on 
his  work  as  before.  There  is  headache,  particularly  at 
the  vertex  and  occiput.  Pain  at  the  vertex  is  described 
as  "pressure" ;  that  at  the  back  of  the  neck  and  occiput 
as  "drawing,"  and  one  feels  an  instinctive  desire  to  sus- 
tain the  head  with  the  hands.  A  vise-like  constriction 
of  the  head  is  sometimes  complained  of.  One  breaking 
down  with  neurasthenia  neglects  his  business  little  by 
little.  He  procrastinates  and  shuns  active  effort,  finds 
it  difficult  to  maintain  his  former  relations  to  society, 
and  by  degrees  drops  out  of  it.  He  suffers  from  pain 
in  the  back  and  legs,  talks  of  sexual  incapacity,  is 
sexually  weak,  is  constipated,  and  is  fatigued  by  exer- 
tion. He  finds  himself  in  a  clammy  perspiration  after 
the  slightest  expenditure  of  force,  is  hypochondriacal, 
is  bent  upon  talking  about  his  symptoms,  and  does  this 
in  season  and  out  of  season.  He  imagines  the  kidneys 
do  not  act  properly,  that  the  blood  is  stagnant,  and  that 
the  functions  of  different  organs  are  inhibited  or  lost. 
Frequently  there  is  complaint  of  great  exhaustion  after 
a  movement  of  the  bowels.  There  are  local  ansesthe- 


INSANITY.  79 

sias,  or  painful  points  at  the  distribution  of  the  super- 
ficial nerves.  v  Patients  become  extremely  sensitive; 
they  lie  in  bed,  demand  unremitting  attention,  cannot 
brook  the  slightest  noise  about  the  house,  insist  upon 
closely  drawn  curtains,  and  cover  the  eyes  to  exclude 
light. 

They  complain  of  lack  of  appetite,  restrict  them- 
selves to  the  lightest  possible  diet,  develop  foolish  fads 
in  eating,  and  imagine  they  must  place  dependence 
upon  so-called  "health  foods."  They  complain  of 
digestive  symptoms,  particularly  of  pain  in  the  stom- 
ach, and  gaseous  eructations.  They  suffer  from  in- 
somnia and  demand  medicine  for  the  relief  of  this 
condition.  The  faculty  of  voluntary  attention  is  im- 
paired. There  is  occasionally  the  unfounded  fear  of 
syphilitic  infection.  Unless  carefully  safeguarded  they 
are  apt  to  become  confirmed  drug  takers.  There  is  a 
disposition  to  key  up  with  alcohol  or  narcotics,  which 
disposition,  yielded  to,  aggravates  the  depression  for 
which  the  stimulant  was  taken.  All  symptoms  are 
most  distressing  in  the  early  morning  hours.  Patients 
develop  contractures  and  muscular  atrophy  from  disuse 
of  the  extremities.  One  under  my  care  several  years 
ago  had  been  bedridden  or  confined  to  an  invalid  chair 
for  twenty-five  years.  Her  knees  were  contractured 
and  the  muscles  of  the  thighs  and  legs  almost  com- 
pletely atrophied  from  disuse.  She  was  supposed  to  be 
the  victim  of  spinal  disease  and  had  become,  in 
consequence  of  neuralgic  pains,  a  morphine  habitue. 
The  task  of  lifting  this  patient  from  despondency  andf 
re-establishing  self-confidence  was  very  great,  but  was 
accomplished  in  due  time.  In  neurasthenia  the  tendon 
reflexes  are  invariably  exaggerated. 


80  INSANITY. 

Diagnosis. — Many  cases  of  paretic  dementia  of  the 
apathetic  or  depressed  type  have  been  early  diag- 
nosticated as  neurasthenia.  Marked  impairment  or 
absence  of  memory  with  pupillary  abnormalities  (con- 
tracted pupils,  unequal  pupils,  or  pupils  of  the  Argyll- 
Robertson  type)  constitute  practically  conclusive  evi- 
dence of  the  former  condition.  The  Wassermann 
reaction  and  spinal  fluid  examination  discussed  under 
the  head  of  Paretic  Dementia  may  be  useful  here  for 
diagnostic  purposes.  An  objection  to  this  and  to  any 
surgical  procedure  lies  in  the  danger  of  adding  one 
more  item  to  the  patient's  repertoire  of  disabilities. 

Treatment. — The  implication  of  the  sympathetic 
nervous  system  in  neurasthenic  states  is  so  pronounced 
in  the  symptomatology  that  to  mention  the  one  with- 
out immediate  mental  association  with  the  physiology 
of  the  other  is  impossible.  The  vascular  phenomena — 
contraction-dilatation,  the  fluctuations  of  pallor  and 
flushing,  the  delayed  digestion,  the  rectal  pain,  the 
dilatation  of  the  intestines  and  diminished  peristalsis, 
the  epigastric  discomfort,  the  sudden  perspiring — all 
point  to  an  extremely  mobile  state  of  this  particular 
division  of  the  nervous  system.  In  its  treatment  ergot 
and  small  doses  of  atropine  are  indicated. 

Change  of  environment  is  of  the  utmost  value  and 
the  hospital  or  sanitarium  regime  ideally  adapted. 
Rapid  change  of  scene,  as  travel,  is  not  often  pro- 
ductive of  good.  A  patient  going  about  from  place  to 
place,  consults  one  physician  and  another,  and  is  con- 
fused and  made  more  self-centered  by  conflicting 
opinions  and  differing  medical  prescriptions.  The  de- 
termination of  the  question  of  location  should  be  made 
by  others,  and  the  carrying  out  of  a  wise  plan  of  treat- 


INSANITY.  81 

ment  for  a  number  of  months  should  be  enjoined  and 
insisted  upon.  Medicines  to  build  up  the  general  health 
and  directed  to  disease  of  the  stomach  and  intestines 
should  be  employed.  The  bowels  should  be  kept 
regular  by  the  use  of  aperients  and  the  colon  flushing. 
Diastasic  essence  of  pancreas  is  a  useful  remedy  for 
the  frequently  attendant  intestinal  indigestion.  Medi- 
cine directed  to  the  excess  or  diminution  of  hydro- 
chloric acid  in  the  stomach,  the  necessity  for  which 
may  be  determined  by  an  analysis  of  the  stomach  con- 
tents, may  be  employed.  Electric  massage,  mechanical 
vibration  of  the  muscles,  and  the  static  breeze  are  of 
service,  the  latter  particularly  for  its  suggestive  and 
.soothing  effect.  Hydrotherapy,  particularly  the  Rus- 
sian bath  and  salt  rub,  followed  by  the  cold  spray  to 
the  spine  and  vigorous  friction,  are  particularly 
valuable. 

For  the  frequently  attendant  insomnia,  a  hot  drink 
should  be  given  at  bedtime.  If  after  a  fair  trial  that 
proves  insufficient,  recourse  may  be  had  to  veronal, 
sulfonal,  or  trional  in  small  dose.  The  habit  of  de- 
pendence upon  hypnotics  is  rapidly  developed,  how- 
ever, and  the  danger  of  it  should  be  conscientiously 
borne  in  mind.  After  all,  as  a  matter  of  fact,  depress- 
ing medicines  are  distinctly  contraindicated  in  such 
cases  and  are  detrimental  if  much  employed.  Such 
patients  are  susceptible  to  suggestion,  and  a  confident 
manner  of  administration  goes  far  to  increase  the  effi- 
cacy of  remedies. 

A  patient  once  declared  that  the  medicine  called 
"placebo"  helped  her  the  most  of  any.  Given  with  as- 
surance it  will  often  be  found  useful  in  the  sleepless- 
ness of  neurasthenia. 


82  INSANITY. 

Intoxication  Psychoses. 

These  may  develop  from  any  poisonous  substance 
taken  into  the  body,  prominent  among  which  are  alco- 
hol, opium  and  its  preparations,  cocaine,  hemp,  the 
ptomaines,  and  preparations  of  lead. 

LEAD  POISONING  produces  a  train  of  symptoms  like 
those  of  organic  brain  disease.  There  are  the  charac- 
teristic paralyses  of  lead  with  possible  colic;  there  are 
tremors,  pains  in  the  limbs,  incoherence  of  speech,  con- 
fusional  states,  sometimes  delusions  of  fear,  and  occa- 
sionally epileptiform  convulsions.  Inquiry  into  the 
habits  of  life  and  the  occupation  of  the  patient  usually 
suffices  to  differentiate  this  condition  from  organic  de- 
mentia. The  treatment  should  be  directed  to  the  elim- 
ination of  the  poison  of  the  presence  of  which  the 
nervous  symptoms  are  an  expression. 

ALCOHOLIC  INTOXICATION. — The  phenomena  of 
acute  alcoholic  intoxication  are  so  well  known  as  to 
require  no  extended  notice.  However,  given  a  condi- 
tion of  habitual  inebriety  and  the  erraticism  incident 
thereto,  it  may  be  puzzling  at  times  to  decide  at  what 
period  disturbance  of  thinking,  feeling,  and  acting  has 
reached  the  morbid  degree,  where  responsibility  leaves 
off  and  unaccountability  for  conduct  begins.  Varying 
with  the  natural  disposition,  there  may  be  in  simple 
intoxication  exaltation  or  depression  of  emotional  toner 
belligerency,  jealousy,  periods  of  frenzy,  stupor,  de- 
pending upon  the  amount  of  intoxicants  taken  into 
the  system. 

DELIRIUM  TREMENS. — Acute  alcoholic  delirium,  or 
delirium  tremens,  is  of  sudden  onset,  though  there  is 
frequently  an  antecedent  period  of  gastric  derangement 


INSANITY.  83 

with  reduction  in  emotional  tone,  and  impaired  nutri- 
tion, due  to  the  toxic  effects  of  alcohol.  The  delirious 
condition  arises  in  some  cases  during  a  prolonged 
drinking  bout,  in  others  after  withdrawal  of  the  habit- 
ual stimulant.  Occasionally  it  develops  as  the  imme- 
diate result  of  an  injury.  The  susceptibility  to  delirium 
following  fracture  in  subjects  addicted  to  prolonged 
alcoholic  indulgence  is  a  matter  of  frequent  observa- 
tion. Following  the  period  of  insomnia,  of  derange- 
ment of  the  stomach  and  alimentary  canal,  loss  of 
appetite,  and  restlessness,  a  condition  of  mental  excite- 
ment appears.  There  are  increased  sensitiveness  and 
irritability,  fretfulness,  and  impatience.  Rapidly  a 
condition  of  confusion  supervenes  and  this  goes  on  to 
delirium,  more  or  less  grave  and  pronounced,  depend- 
ing upon  the  amount  of  intoxicant  consumed  and  the 
susceptibility  of  the  patient  to  its  influence.  Hallu- 
cinations of  sight  and  hearing  take  place.  Patients 
hear  threatening  noises  and  misconstrue  ordinary  con- 
versation and  current  sounds.  They  are  suspicious. 
They  see  rats,  vermin,  and  creeping  and  crawling 
things,  dogs,  cats,  horses,  and  things  going  'round  and 
'round.  They  distort  figures  in  the  carpet  and  wall 
paper,  pick  at  the  bedding,  and  are  by  turns  incoherent, 
dazed,  frenzied,  and  completely  disoriented.  They  are 
impulsive  and  violent,  and  are  apt  to  exhaust  their 
strength  to  the  border  of  collapse  by  struggling  with 
those  about  them.  From  time  to  time  during  the 
progress  of  delirium  there  is  a  half-conscious  apprecia- 
tion of  the  surroundings  and  the  absurdity  of  morbid 
concepts,  and  the  patient  may  be  momentarily  diverted, 
only  to  become  lost  again  in  vagaries  and  fantastic 
thoughts.  Elevation  of  temperature  and  accelerated 


84  INSANITY. 

pulse  are  commonly  noticed.  During  frenzy,  particu- 
larly if  manual  restraint  has  been  necessary  and  strug- 
gling with  the  patient  has  been  entailed,  there  are 
pallor  of  the  surface,  cold  sweat,  and  indications  of 
impending  collapse.  Refusal  of  food  takes  place  be- 
cause of  loss  of  appetite  and  delusions  of  poison.  Pa- 
tients are  sleepless. 

Treatment. — Patients  should,  if  possible,  have  hos- 
pital or  sanitarium  care  where  special  arrangements 
are  made  to  prevent  self-injury,  where  necessary  re- 
straint may  be  employed  and  unnecessary  coercion 
omitted.  The  room  should  be  dark  and  quiet  and  noise 
minimized.  There  should  be  attention  to  elimination 
by  the  use  of  calomel  and  salines.  Emptying  of  the> 
lower  bowel  by  enemata  and  of  the  colon  by  the  high  • 
flushing  is  of  service.  Patients  should  be  induced  to 
take  as  much  liquid  as  possible  to  favor  elimination 
by  the  kidneys  and  skin.  Where  liquids  are  not  taken 
readily  by  the  mouth  they  may  be  introduced  at  fre- 
quent intervals  by  the  rectum.  The  patient  should  be 
kept  perfectly  quiet.  The  presence  of  a  level-headed 
nurse  is  necessary.  Talking  to  the  patient,  except  oc- 
casionally to  say  a  soothing  or  quieting  word,  should 
'be  omitted.  The  calm  manner  and  assuring  tone  of 
voice  may  be  of  great  service  in  suggesting  to  the 
patient  the  unreality  of  morbid  impressions,  but  much 
conversation  on  any  subject  is  to  be  deprecated.  Tepid 
or  cool  sponging  at  frequent  intervals  is  of  service. 
The  use  of  the  ice-cap  to  the  head  and  to  the  precordial 
region  in  case  of  great  rapidity  of  the  heart's  action  is 
of  much  value.  In  diet,  malted  milk,  digestible  cocoa, 
coffee,  eggnog  without  liquor,  blanc-mange,  floating 
island,  beef  peptonoids,  soups,  and  broths  may  be  used. 


INSANITY.  85 

Rectal  alimentation  is  necessary  in  some  cases  where 
there  is  persistent  refusal  of  food,  and  tube-feeding 
through  the  nose  may  be  demanded.  Medicinally, 
strychnine  is  the  remedy  of  greatest  value.  From  %0 
to  %o  grain  of  strychnine  may  be  given  hypodermically 
once  in  four  or  six  hours  according  to  the  condition  of 
the  heart  and  the  general  symptoms.  Tincture  of 
capsicum  is  valuable  as  a  regular  prescription,  and  may 
be  given  in  doses  of  10  to  15  drops  three  or  four  times 
a  day.  Alcohol  should  be  immediately  withdrawn. 
Other  remedies  besides  those  alluded  to,  as  kola,  coca, 
quinine,  the  aromatic  spirit  of  ammonia,  may  be  given 
throughout  waking  hours  and  furnish  an  entirely  satis- 
factory substitute  for  alcohol.  The  patient  should  be 
allowed  as  much  latitude  as  possible  .consistent  with 
the  preservation  of  strength.  In  the  intervals  of  cold 
applications  to  the  head  he  may,  to  rest  himself,  be  per- 
mitted to  walk  about  the  room.  When  heart  failure 
is  threatened,  however,  confinement  to  bed  should  be 
enjoined  and  mechanical  restraint  used  if  necessary  to 
insure  this.  Of  sleep-producing  remedies,  the  best  in 
these  conditions,  in  my  judgment,  is  chloral.  It  is 
rarely  necessary  to  give  more  than  two  doses  of  the 
drug,  20  grains  at  each  dose,  three  hours  apart.  It  may 
be  given  in  connection  with  the  valerianate  of  am- 
monia, with  quinine,  or  with  strychnine,  and  the  addi- 
tion of  one  of  the  latter  remedies  where  cardiac  ex- 
haustion threatens  is  desirable.  In  private  practice  in 
the  treatment  of  these  cases,  chloral  is  a  much-used 
and  often-abused  drug.  Under  home  surroundings, 
the  necessity  for  quieting  the  patient  at  any  hazard 
leads  to  large  and  frequent  doses  of  chloral  combined 
with  bromide  of  potassium.  A  state  of  confusion  is 


86  INSANITY. 

induced ;  there  is  serious  reduction  of  the  vital  forces ; 
elimination  is  checked  and  toxins  are  retained. 

Other  hypnotics,  as  veronal,  sulfonal,  and  trional, 
may  be  used  as  necessary,  and  will  be  frequently  found 
valuable.  It  may  be  expedient  to  give  small  doses  of 
bromide  of  potassium,  10  to  15  grains,  at  intervals  of 
four  or  five  hours,  where  there  is  great  nervous  excite- 
ment, but  this  should  be  omitted  otherwise.  I  am  op- 
posed to  the  use  of  morphine  and  codeine  in  these 
cases,  although  in  some  instances  they  may  be  required 
to  quiet  extreme  nervous  agitation.  Paraldehyde  is  in 
many  cases  invaluable  in  the  insomnia  due  to  with- 
drawal of  alcoholic  stimulants.  One  patient  whose 
whims  were  most  difficult  to  meet  spoke  of  the  com- 
fortable "glow"  after  its  ingestion.  It  is,  in  fact,  so 
very  acceptable  that  the  danger  of  establishing  depend- 
ence upon  it  must  be  borne  in  mind.  It  may  be  pre- 
scribed in  doses  of  1  to  2  drams  and,  as  a  rule,  one 
dose  will  suffice.  To  disguise  its  pungent  taste  the 
addition  of  gum  acacia,  oil  of  wintergreen,  and  syrup 
of  wild  cherry,  after  the  formula  of  Shoemaker,  is 
useful. 

DIPSOMANIA. — In  certain  cases  where  there  is  strong 
hereditary  instability,  the  disposition  to  drink  to  excess 
comes  in  waves  or  storms.  There  may  be  months  of 
total  abstinence  or  temperance,  then  of  a  sudden  the 
unfortunate  individual  is  engulfed  in  the  whirlpool  of 
indulgence.  He  leaves  his  business,  however  pressing 
and  important  it  may  be,  goes  to  an  unfrequented  part 
of  his  city  or  to  a  distant  point,  and  for  days  or  weeks 
indulges  the  appetite  to  drink  to  the  limit.  Clearing 
up  comes  as  suddenly.  A  tapering  off  process  begins. 
There  are  needed  a  few  doses  of  the  bromides,  two  or 


INSANITY.  87 

three  seances  at  the  Turkish  bath,  and  the  wreck  of  the 
week  before,  now  rehabilitated,  resumes  his  place  at 
the  desk  or  in  the  counting-room,  clothed  and  in  his 
right  mind.  The  disease  manifesting  itself  thus  is 
called  dipsomania,  a  term  which  is  properly  applied  to 
this,  and  only  this,  form  of  alcoholic  inebriety. 

CHRONIC  ALCOHOLISM  is  attended  by  progressive 
mental  deterioration  and  by  physical  symptoms  denot- 
ing change  in  the  central  nervous  system.  The  patho- 
logical changes  are  those  due  to  arteriosclerosis,  menin- 
gitis, and  "cerebral  atrophy.  Progressive  impairment  of 
memory  and  attention  occurs ;  there  is  failure  of  judg- 
ment and  inability  to  carry  on  business  in  a  satisfactory 
manner.  The  conversation  is  mixed  and  there  is  de- 
terioration in  personal  habits.  The  moral  ideals  are 
lowered,  there  is  an  ignoring  of  conventions;  from 
being  careful  in  manner  and  speech  one  becomes  coarse 
and  unrefined,  unreasoning  prejudices  are  developed, 
and  patients  are  at  sixes  and  sevens  with  relatives. 
There  are  inconsistent  complainings;  patients  believe 
themselves  deprived  of  opportunities  and  attribute  to 
others  the  lack  of  success  which  the  vicious  indulgence 
has  brought  about.  Natural  affection  disappears. 

ALCOHOLIC  DELUSIONAL  INSANITY. — A  step  further 
in  the  degenerative  process  and  there  are  well-marked 
delusions.  With  patients  who  are  married  the  idea  of 
infidelity  on  the  part  of  the  wife  or  husband  is  fre- 
quently present.  The  basis  for  this  is  often  sexual 
repugnance,  on  the  one  side,  or  inadequacy  on  the 
other.  There  is  extreme  irritability.  Persecutory  de- 
lusions are  present.  Hallucinations  of  hearing  are  fre- 
quent; the  patient  hears  voices  threatening  him,  ac- 
cusing him  of  crime,  and  his  wife  of  infidelity.  At  this 


88  INSANITY. 

stage  there  is  frequently  a  strong  prejudice  against 
alcohol  in  any  form.  I  have  often  known  patients  in 
debilitated  condition  for  whom  an  eggnog  or  light 
alcoholic  stimulant  was  prepared,  to  refuse  it  abso- 
lutely. There  seems  to  develop  a  distaste  for  the 
habitual  stimulant.  There  may  or  may  not  be  tremor 
and  indications  of  muscular  weakness. 

ALCOHOLIC  PSEUDO-PARESIS. — In  certain  cases  of 
chronic  alcoholism  there  develop  symptoms  simulating 
those  of  organic  brain  disease.  There  are  present  fine 
muscular  tremor,  ataxia,  muscular  atrophy,  uncertainty 
in  gait,  defective  speech,  frequent  headaches,  vertigo, 
exaggeration  of  tendon  reflexes,  loss  of  memory,  and 
epileptiform  attacks.  The  gait  is  often  peculiar;  the 
patient  walks  with  rapidity,  but  showing  muscular 
inco-ordination,  comes  to  sudden  stops,  then  rushes  on 
as  before.  He  is  unable  to  give  himself  satisfactory 
attention  in  dressing,  the  personal  habits  become  un- 
tidy, there  is  fibrillary  twitching  of  the  tongue:  the 
memory  is  feeble,  the  patient  cannot  find  his  room, 
he  is  unable  to  write,  and  if  he  undertakes  this  the 
result  is  a  sorry  scrawl.  There  is  at  times  a  tendency 
to  extreme  somnolence.  The  reflexes  are  often  exag- 
gerated to  that  extent  that  muscular  contraction  takes 
place  throughout  the  entire  extremity  by  tapping  the 
patellar  tendon.  Along  with  the  extreme  muddling 
and  mental  confusion,  there  are  hallucinations  of  hear- 
ing. One  patient  heard  girls  making  merry  outside 
his  window,  another  the  noise  of  a  sewing  machine. 
There  may  be  impressions  of  water  running  through 
the  ceiling.  Patients  imagine  their  lives  are  threatened 
and  hear  pistol  shots.  The  recollection  of  incidents 
during  active  excitement  is  much  disturbed,  and  un- 


INSANITY.  89 

founded  prejudices  arise  against  those  having  the  care 
of  the  patient. 

Alcoholic  pseudo-paresis  may  be  mistaken  for  true 
paretic  dementia.  In  a  marked  case  which  came  under 
my  observation  some  years  ago  there  were  extravagant 
delusions,  the  pin-hole  pupil,  indistinctness  in  articu- 
lation, visceral  delusions,  and  marked  ataxia  in  gait 
and  speech.  Regis  says  that  inequality  of  pupils  is 
scarcely  ever  lacking  in  alcoholic  pseudo-paresis.  The 
pupillary  aperture  may  be  misshapen,  the  pupil  dull 
and  cloudy,  and  visual  acuteness  less.  The  ataxic 
symptoms  rapidly  clear  up  after  active  elimination, 
rest,  and  quiet.  Bevan  Lewis  speaks  of  the  motor  dis- 
turbance in  alcoholic  pseudo-paresis  as  motor  impo- 
tence, not  inco-ordination.  The  earliest  indication  is 
a  fine  muscular  tremor,  implicating  first  the  fingers 
and  hand,  gradually  spreading  to  the  arm,  next  involv- 
ing the  tongue,  lips,  and  articulatory  muscles  generally, 
and  lastly  extending  to  the  foot  and  leg.  The  occur- 
rence of  epileptiform  seizures  similar  to  those  appear- 
ing in  the  progress  of  paretic  dementia,  complicates  the 
diagnosis  in  a  small  number  of  cases.  The  seizures  are 
in  no  respect  different  from  those  encountered  in  true 
paretic  dementia.  Occurring  in  connection  with  slug- 
gish and  unequal  pupils,  exaggerated  tendon  reflexes, 
ataxia,  incoherent  speech,  untidiness  in  habits,  halluci- 
nations of  hearing,  extreme  mental  confusion,  dis- 
orderliness  of  conduct,  general  obtunding  of  the  mental 
faculties,  and  loss  of  control  over  the  sphincters,  as 
was  the  case  in  a  patient  who  recovered,  a  correct  diag- 
nosis in  the  early  stages  of  the  malady  may  be  impos- 
sible. In  one  case  displaying  this  train  of  symptoms, 
the  mental  disturbance  disappeared  entirely  during  the 


90  INSANITY. 

first  month,  and  within  three  months  the  reflexes, 
theretofore  greatly  exaggerated,  were  normal,  there 
was  no  evidence  of  ataxia,  there  were  equal  pupils  and 
distinct  articulation.  The  handwriting  was  good.  Ex- 
perience in  this  and  other  cases  would  seem  to  empha- 
size the  importance  of  careful  inquiry  into  etiology  and 
sufficient  observation  of  the  case  after  withdrawal  of 
the  stimulant  and  complete  rest  to  make  sure  of  the 
diagnosis.  Cases  of  this  kind  may  progress  with  but 
slight  involvement  of  pulse  and  temperature. 

A.  W.  Hurd  writes  of  differential  diagnosis  as  fol- 
lows: "The  motor  symptoms  in  paresis  are  generally 
more  localized  than  in  alcoholic  dementia — the  seats  of 
election  at  first  being  more  especially  in  the  muscles  of 
locomotion  and  articulation,  while  in  alcoholism  the 
tremor  and  trembling  are  more  generally  distributed; 
with  the  general  tremor,  real  muscular  weakness  is 
more  marked  than  in  paresis.  In  the  early  period  the 
trembling  of  the  hands  is  more  conspicuous  than  in 
paresis,  while  the  inco-ordination  is  apt  to  be  less.  The 
interference  with  the  muscles  of  articulation,  while 
possibly  present  in  both,  is  more  pronounced  in  paresis, 
and  the  elision  of  syllables,  the  omission  of  syllables  or 
letters,  quite  characteristic,  but  difficult  to  describe,  is 
more  pronounced — while  in  alcoholism  the  difficulty 
of  articulation  appears  to  be  a  more  constant  general 
tremor  of  the  muscles,  without  the  lapses  and  spas- 
modic pauses." 

A  positive  Wassermann  reaction  and  the  findings 
from  spinal  fluid  examination  may  serve  to  practically 
clear  the  diagnosis.  (See  page  125.) 

Treatment. — Withdrawal  of  alcohol  and  a  tonic  non- 
alcoholic medicinal  regimen  are  necessary.  Strychnine 


INSANITY.  91 

in  small  doses,  three  times  a  day,  is  a  valuable  tonic. 
When  the  rest  is  disturbed  it  may  be  promoted  by 
taking  some  warm  drink  at  bedtime.  Especial  atten- 
tion should  be  paid  to  elimination.  The  patient  should 
take  large  quantities  of  water.  A  nourishing  diet 
should  be  prescribed.  Hydrotherapy  is  of  great  im- 
portance. The  steam  bath,  and  subsequent  salt  glow 
and  shower,  are  of  value.  Effort  should  be  made  to 
build  up  the  general  health  by  out-of-door  exercise  and 
indoor  calisthenics.  Games  and  other  diversions  are 
of  much  service. 

ALCOHOLIC  PARANOIA. — The  delusional  state  in  cer- 
tain cases  of  alcoholic  insanity  may  simulate  paranoia. 
Women  suffering  from  this  disease  believe  themselves 
to  be  queens  and  persons  of  superior  birth.  There  are 
delusions  of  suspicion  and  of  conspiracy.  The  conver- 
sation is  frequently  indecent;  the  wife  believes  herself 
persecuted  by  her  husband,  who  plans  to  have  her 
killed  in  a  runaway  accident  to  obtain  imaginary  life 
insurance.  The  patient  may  feel  much  responsibility 
resting  upon  her  and  be  impelled,  as  in  a  case  of  my 
own,  to  make  bread  and  butter  by  opening  and  closing 
the  window.  There  are  extravagant  fancies.  Useless 
purchases  are  made;  the  dress  is  fantastic.  One  may 
write  poetry  and  imagine  herself  an  accomplished 
musician  or  authoress;  that  her  treatment  away  from 
home  is  a  sacrifice  because  of  some  understanding  with 
another  government.  There  are  hallucinations  of 
hearing,  messages  are  conveyed  through  speaking- 
tubes,  and  communications  sent  out  by  turning  the 
handles  of  water  coolers.  A  symbolical  significance  is 
discovered  in  a  picture,  in  the  disposition  of  some 
article  of  furniture,  or  in  table  arrangements.  One 


92  INSANITY. 

patient  who  murdered  his  wife  by  striking  her  on  the 
head  with  an  axe  committed  the  act  because  he  read 
in  lettuce,  radishes,  and  onions  served  at  one  time  on 
the  table,  "Let  us  re-disunion." 

Treatment. — The  general  considerations  pertaining 
to  the  treatment  of  chronic  insanities  apply  to  the  care 
of  these  conditions. 

ALCOHOLIC  EPILEPSY. — Occasionally  grave  epilepti- 
form  attacks  occur  without  the  accompanying  mani- 
festations of  ataxia  mentioned  under  the  head  of 
Alcoholic  Pseudo-paresis.  Indeed,  a  sudden  nervous 
explosion  of  this  character  may  be  the  first  warning 
received  by  the  patient  that  his  or  her  drinking  is  ex- 
ceeding the  bounds  of  moderation.  A  strikingly 
interesting  incident  of  this  kind  was  observed  in  the 
case  of  a  woman  patient  of  mature  years.  Seizures  of 
an  epileptoid  character  occurred  after  intervals  of  a 
week  or  fortnight.  There  was  profound  unconscious- 
ness and  injury  was  done  to  the  head  in  a  fall  accom- 
panying one  of  the  attacks.  This  patient  showed  no 
sign  of  deterioration  in  intellect  or  in  the  motor  sphere 
and  made  an  excellent  recovery  consecutive  upon  the 
withdrawal  of  alcoholic  stimulants  and  upbuilding  the 
general  health. 

MORPHINE  AND  OPIUM  ADDICTION. — Causes:  I  am 
by  no  means  prepared  to  admit,  after  the  treatment  of 
morphine  and  opium  addiction  for  many  years,  that  the 
majority  or  more  than  a  large  percentage  of  cases  are 
due  to  the  injudicious  prescription  of  the  physician. 
While  some  develop  "because  of  the  continuance  of  a 
physician's  prescription  (often  without  his  knowledge) 
for  an  undue  length  of  time,  many  originate  from  pure 
self-indulgence.  It  is  true  in  all  probability  that  mor- 


INSANITY.  93 

phine  is  used  too  liberally  in  the  treatment  of  neu- 
ralgic conditions.  It  is  too  frequently  the  first  re- 
sort and  one  dose  is  followed  by  another  and  another 
until  the  patient  is  under  the  tyranny  of  the  habit. 
Unfortunately,  those  to  whom  narcotic  drugs  are  easily 
accessible,  as  physicians  and  pharmacists,  who  know 
perfectly  well  the  dangers  which  menace  one  in  the 
employment  of  drugs  habitually,  fall  into  the  way  of 
taking  opium  or  some  of  its  extractives  in  the  place  of 
some  other  form  of  stimulant.  A  physician  after  an 
arduous  day's  work  finds  it  convenient  to  secure  rest 
and  repose  by  taking  a  small  hypodermic  injection.  He 
has  a  feeling  of  indifference  to  its  danger,  is  aware  of 
the  insidiousness  of  the  drug  and  the  horrors  attendant 
upon  its  habitual  use,  but  takes  it  with  that  confidence 
in  employing  the  tools  of  his  profession  which  familiar- 
ity breeds. 

Uncomplicated  cases  of  morphine  addiction  are  rarer 
than  formerly.  In  not  a  few  instances  cocaine  is  re- 
sorted to  at  the  time  the  depressing  effect  of  the  first 
taken  narcotic  falls  upon  the  patient.  This  complica- 
tion adds  to  the  difficulties  in  the  way  of  treatment. 
On  the  contrary,  one  of  the  least  difficult  patients  it 
has  been  my  experience  to  treat  had  regularly  taken 
stimulating  drugs  with  the  morphine.  He  had  had 
every  two  hours  or  thereabouts  3  grains  of  acetanilid, 

2  grains  of  citrated  caffeine,  1  grain  bicarbonate  soda, 
%  grain  morphine,  %00  grain  nitroglycerin,  2  drops 
tincture  digitalis,  2  drops  tincture  strophanthus,  %0 
grain  strychnine.    In  addition  to'this  he  had  consumed 
on  the  day  preceding  my  first  interview  with  him,  some 

3  pints  of  whisky.     It  would  seem  from  the  rapidity 
with    which   this    case    responded   to   treatment   that 


94  INSANITY. 

the  cardiac  tonics  had  to  some  extent  counteracted  the 
depressing  effects  of  the  morphine.  Another  case 
which  came  under  my  observation  was  taking  every 
four  hours  %0  grain  sulphate  of  strychnine;  1%  grains 
each  salol  and  charcoal;  6  grains  subnitrate  of  bis- 
muth ;  %  grain  extract  of  nux  vomica ;  also  at  intervals 
12  grains  of  acetate  of  potash  and  10  minims  spirit  of 
nitrous  ether,  paraldehyde  (a  small  teaspoonful  every 
hour),  and  of  morphine  26  grains  in  twenty-four  hours 
in  divided  doses.  Such  cases  as  these  are  exceptional, 
but,  as  heretofore  remarked,  uncomplicated  morphine 
cases  are  less  frequently  observed  than  in  former  years. 

The  active  life,  great  anxiety,  push,  work,  and  at- 
tendant sleeplessness  necessitated  by  modern  business 
methods  are  all  factors  in  drug  habituation.  In  states 
of  nervous  exhaustion  there  is  recourse  to  alcoholics 
and  to  narcotic  drugs  for  temporary  relief.  A  chronic 
diarrhoea  may  have  occasioned  the  first  dose  of  lauda- 
num, paregoric,  or  "Sun  cholera  mixture."  A  fruitful 
source  of  opium  and  morphine  addiction  is  the  pres- 
ence of  one  mischievous  person  who  is  a  confirmed 
habitue.  I  have  known  a  whole  neighborhood  to  be 
infected  indirectly  by  a  single  individual  of  this  char- 
acter. 

The  amount  of  the  drug  consumed  becomes  progress- 
ively greater,  and  the  system  may  become  habituated 
to  inordinately  large  quantities.  From  the  smaller  dose 
there  is  a  feeling  of  temporary  well-being.  This  gives 
place  after  a  time  to  lassitude  and  apathy ;  another  dose 
is  required  of  a  larger  amount,  and  thus  from  day  to 
day  the  quantity  is  increased,  the  patient  meanwhile 
making  fruitless  attempts  at  reduction. 

The  characteristics  of  the  chronic  morphine  habitue 


INSANITY.  95 

are  restlessness,  emotionality,  irritability,  brightness 
alternating  with  dullness,  gaiety  with  moodiness. 
There  are  ineptitude  for  business,  incapacity  for 
mental  application,  suspiciousness.  Nausea  is  a 
common  symptom;  there  are  painful  neuralgias,  in- 
somnia, disturbance  of  the  heart's  action  and  of  the 
functions  of  the  bowels  and  kidneys.  The  patient  is 
unreliable  and  distrustful.  He  or  she  takes  every 
means  to  secure  the  drug  without  the  knowledge  of 
family  or  friends,  and  becomes  secretive  and  dishonest. 
It  is  difficult  to  obtain  from  one  habituated  to  the  use 
of  morphine  an  accurate  statement  of  the  amount  of 
the  drug  ingested  in  twenty-four  hours. 

Treatment. — Absolute  rest  and  restraint  are  prac- 
tically indispensable  for  the  successful  treatment  of 
these  cases.  Separation  from  home  and  friends  is 
essential,  both  that  the  patient  may  be  prevented  from 
indulging  in  the  habit  and  to  thwart  the  injudicious  at- 
tentions of  interested  and  over-indulgent  relatives. 
There  should  be  at  first  active  elimination  by  the  use 
of  calomel,  or  calomel  and  podophyllin  followed  by 
salines.  Nearly  all,  indeed  all  except  a  small  fraction 
of  the  habitual  dose  of  the  drug,  may  be  withdrawn  at 
once.  The  patient  should  be  put  to  bed  and  for  a  few 
days  receive,  at  intervals  of  four  or  six  hours,  a  small 
amount,  say  a  quarter  to  half  a  grain  of  morphine  in 
connection  with  strychnine,  hypodermically.  By  the 
mouth  there  may  be  given  quinine,  strychnine,  kola, 
coca,  capsicum,  and  Jamaica  dogwood  as  indicated.  A 
small  dose  of  one  or  other  of  these  drugs  frequently 
administered  is  comforting  to  the  patient,  and  is  useful 
in  enabling  him  to  bear  the  withdrawal  of  the  more 
active  stimulant.  Let  kola,  coca,  and  valerianate  of 


96  INSANITY. 

ammonia  be  given  at  one  time;  strychnine  %0  two 
hours  later ;  capsicum  10  to  20  minims  in  two  hours ; 
two  hours  later  2  grains  of  quinine;  strychnine  again 
in  two  hours ;  then  return  to  the  first  prescription.  The 
patient  is  interested;  a  measure  of  quiet  is  produced 
and  the  heart  action  supported.  Strychnine  and  what- 
ever small  quantity  of  morphine  or  codeine  is  allowed 
may  be  given  hypodermically ;  the  other  remedies,  by 
the  mouth  or  bowel,  according  to  the  condition  of  the 
alimentary  canal.  The  important  point  is  the  short 
intervals  of  administration  and  the  change  from  one 
drug  help  to  another. 

Within  two  or  three  days  the  amount  of  morphine 
may  be  diminished  by  one-half,  and  within  a  week  the 
substitution  of  codeine  may  be  made  without  serious 
disturbance  of  the  heart's  action.  It  is  important  to 
watch  the  latter  condition  and  to  regulate  by  it  the  ad- 
ministration of  remedies.  During  the  early  days  of 
treatment  a  hypnotic,  in  addition  to  a  small  amount 
of  morphine,  will  be  required.  The  one  that  is  per- 
haps all  round  the  most  serviceable  is  veronal,  but 
sulfonal,  trional,  medinal,  and  chloral  are  adapted. 
The  average  dose  of  veronal  is  about  10  grains.  The 
patient  should  be  kept  in  bed  to  sustain  his  strength. 
There  should  be  warm  sponge  baths  and  massage  of  the 
extremities,  particularly  the  lower  extremities,  to  re- 
lieve the  dull  ache  which  is  a  constant  accompaniment 
of  the  withdrawal  of  the  drug.  It  is  important  that  the 
patient  should  not  be  taken  into  confidence  as  to  the 
details  of  treatment.  He  should  be  told  that  informa- 
tion as  to  what  is  given  at  any  time  until  he  is  well 
cannot  be  communicated.  This  permits  the  substitu- 
tion of  innocuous  hypodermic  preparations  at  the  time 


INSANITY.  97 

the  patient  expects  to  receive  the  narcotic,  and  although 
he  is  perhaps  not  always  deceived,  the  placebo  is  at 
times  sufficient  to  comfort  him.  Within  ten  days  all 
preparations  of  opium  may  be  withdrawn  absolutely. 
The  other  remedies  may  be  dispensed  with  one  by  one, 
the  intervals  of  their  use  made  longer,  the  strychnine 
being  continued  in  %0-grain  doses  four  times  a  day. 
The  diet  during  active  treatment  should  be  light  and 
nourishing,  care  being  taken  that  the  stomach  is  not 
disordered  by  too  free  alimentation.  Occasionally  it  is 
desirable  to  supplement  mouth  feeding  by  administra- 
tion of  foods  by  rectum.  Convalescence  is  usually 
rapid  after  the  narcotic  drugs  are  withdrawn.  The 
patient's  appetite  becomes  good,  he  begins  to  pick  up 
in  flesh,  and  is  able  to  take  more  and  more  exercise. 
As  soon  as  the  strength  will  permit,  hydrotherapy,  par- 
ticularly the  cold  sponging  and  shower,  should  be  made 
use  of  as  a  tonic  to  the  nervous  system.  As  a  rule,  it 
is  desirable  to  keep  such  patients  under  treatment  and 
away  from  opportunities  for  drug  taking  for  at  least 
six  months — better  for  one  year — and  three  months' 
treatment  is  the  minimum  time  in  which  the  system 
may  be  fortified  to  resist  the  morbid  craving.  Once 
out  of  the  toils,  it  is  the  duty  of  the  physician  to  give 
to  such  a  patient  an  open  letter  addressed  to  any  physi- 
cian who  may  have  his  or  her  care  in  future,  that  there 
is  susceptibility  to  morphine,  and  that  it  should  not 
be  employed  except  in  dire  emergency.  It  was 
formerly  my  custom  to  withdraw  at  once  morphine  and 
all  preparations  of  opium  and  trust  to  the  use  of  other 
drugs  to  overcome  the  resultant  depression.  In  this 
form  of  treatment,  however,  there  is  always  shock  to 
the  system,  and  sometimes  dangerous  cardiac  compli- 


98  INSANITY. 

cations.  In  my  experience  death  has  once  occurred 
from  the  abrupt  withdrawal.  This  course  of  treat- 
ment the  patient  insisted  upon,  and  fearing  that  mor- 
phine would  be  administered  without  his  knowledge, 
declined  to  take  other  medicines.  In  the  majority  of 
instances  the  rapid  reduction  of  the  drug  and  treat- 
ment as  outlined  above  is  free  from  dangerous  symp- 
toms, although  during  its  progress  there  are  invariably 
more  or  less  distress,  discomfort,  and  painful  emo- 
tional expression. 

COCAINE  HABITUATION. — As  a  consequence  of  the 
cocaine  habit  a  psychosis  frequently  develops.  Distinct 
mental  perturbation  occurs  and  hallucinations  and  de- 
lusions of  persecution  are  common.  The  leading  fea- 
tures of  the  condition  are  similar  to  those  of  alcoholic 
delirium,  but  there  is  greater  systemic  depression.  In 
my  experience  there  have  been  few  unmixed  cases, 
most  subjects  of  cocaine  having  resorted  to  the  drug 
to  key  up  from  the  secondary  depressing  effects  of  the 
alkaloids  of  opium.  Uncomplicated  cases  of  the  habit 
have,  for  the  most  part,  arisen  from  the  use  of  snuff  or 
nasal  douches  containing  cocaine. 

Treatment. — In  cases  where  the  cocaine  habit  is 
complicated  with  that  of  morphine,  there  is,  as  a  rule, 
no  difficulty  in  the  withdrawal  of  the  former  drug  at 
once,  but  the  patient  will  require  for  many  days  watch- 
ful attention  to  prevent  acts  of  violence  and  self-injury 
and  to  arrest  any  dangerous  impulses  which  the  result- 
ant delirium  may  create.  In  uncomplicated  cases  it  is 
wise  to  administer  for  a  few  days  morphine  or  codeine 
in  small  doses  hypodermically.  To  overcome  the  de- 
lirium the  ice-cap  to  the  head  is  desirable.  Other  prin- 
ciples of  treatment  are  the  same  as  those  set  forth 
under  the  treatment  of  morphine  addiction. 


INSANITY.  99 

Insanities  from  Disturbance  of  Function  of  the 
Thyroid  Gland. 

Two  forms  of  diseases  bearing  distinct  relation  to 
disturbance  of  function  (lack  of  glandular  activity)  in 
the  thyroid  gland  are  recognized.  One  is  associated 
with  myxoedema.  In  this  psychosis  there  are  apathy, 
dullness  of  intellect,  a  constantly  dejected  mien,  occa- 
sionally delusions  of  fear;  there  are  changes  in  the 
skin  and  mucous  membranes  and  in  the  composition  of 
the  blood  which  accompany  myxoedema. 

Treatment. — The  treatment  of  this  condition  con- 
sists in  the  administration  of  thyroid  extract,  tonics, 
and  medicines  to  promote  elimination  and  build  up  the 
general  health. 

CRETINISM. — Another  form  of  disease,  associated 
with  thyroid  disturbance  is  cretinism,  a  disease  of  chil- 
dren, rare  in  this  country,  but  common  in  Switzerland 
in  the  mountainous  regions  among  the  peasants  leading 
narrow  lives,  and  where  there  is  much  intermarrying 
among  those  nearly  related.  There  is  arrest  of  mental 
development  amounting  to  a  condition  of  imbecility. 
There  is  complete  absence  or  degeneration  (goitrous) 
of  the  thyroid  gland,  sometimes  associated  with  dilata- 
tion of  the  cerebral  ventricles.  The  condition  is  hope- 
less as  regards  cure,  but  observers  have  spoken  of 
amelioration  accompanying  the  continuous  use  of 
thyroid  extract. 

HYPO-  AND  HYPERTHYROIDISM. — There  has  of  re- 
cent years  been  considerable  discussion  of  mental 
symptoms  attributable  to  hypothyroidism  (from  di- 
minished secretion)  and  hyperthyroidism  (from  ex- 
cessive secretion)  dependent  upon  disturbances  of 


100  INSANITY. 

function  of  the  thyroid  gland.  Personally,  I  have  been 
unable  to  differentiate  these  two  conditions  in  their 
symptomatology.  Both  are  attended  by  depression, 
anxiety,  fears,  apprehensiveness.  The  emotional  dis- 
turbance is  so  profound  as  to  readily  pass  over  into  a 
persecutory-delusional  state.  The  physical  sign  on  the 
one  hand  of  thyroid  diminution,  on  the  other  of  en- 
largement, may  be  helpful  in  the  diagnosis.  Tachy- 
cardia is  probably  more  frequent  in  hyperthyroidism. 
Both  conditions  are  apt  to  occur  at  the  climacteric 
period  and  the  picture  of  the  disease  on  the  mental  side 
to  bear  likeness  to  that  of  the  presenile  or  involutional 
case.  The  occurrence  of  mental  disturbance  due  to 
either  condition  is  practically  restricted  to  the  female 
sex. 

Treatment. — The  treatment  of  these  cases  should  be 
upbuilding  in  character,  special  attention  being  paid  to 
any  incidental  debility  of  the  heart.  Thyroid  extract 
is  indicated  in  the  hypothyroidism  cases. 

Dementia  Praecox. 

As  the  name  implies,  the  leading  symptoms  of  this 
form  of  disease  are  due  to  an  early  reduction  of  brain 
force.  There  appears  to  be  necessary  to  its  develop- 
ment a  hereditary  tendency  or  the  neuropathic  organi- 
zation. 

Under  the  head  Dementia  Prsecox  are  included 
various  cases  described  under  the  old-time  classifica- 
tion as  insanity  of  pubescence,  insanity  of  masturba- 
tion, ovarian  insanity,  katatonia,  stuporous  melan- 
cholia. It  is  a  disease  of  early  life  and  a  dementing 
process  from  the  beginning.  As  school  children,  some 


INSANITY.  101 

of  these  patients  are  bright  and  receptive,  learn  easily, 
are  responsive,  and  show  quick  nervous  reaction  and 
impressionability.  Others  have  difficulty  in  keeping  up 
with  their  classes.  While  perception  and  memory  are 
good,  reasoning  and  judgment  are  not  correspondingly 
developed.  They  are  erratic  and  lacking  in  inhibitory 
control.  They  are  subject  to  headache  and,  if  pressed, 
frequently  break  down  in  school  work.  They  are  sub- 
ject to  attacks  of  dreamy  abstraction  and  find  it  diffi- 
cult to  concentrate  the  attention.  In  some  instances 
erraticism  goes  over  by  imperceptible  degrees  into  pro- 
nounced mental  perturbation.  In  others  there  is  a 
sudden  change  from  the  habitual  states  of  feeling  and 
acting.  This  may  appear  coincident  with  the  period 
when  the  boy  becomes  a  man  or  the  girl  a  woman.  It 
may  be  that  the  determining  cause  is  a  fever,  an  injury, 
or  some  shock  to  the  nervous  system.  '  Symptoms  of 
acute  depression  or  excitement  occur,  followed  by  a 
characteristic  train  of  symptoms  depending  upon  the 
form  which  the  disease  assumes  and  of  which  three 
classes  of  cases  are  recognized:  the  hebephrenic,  the 
katatonic,  and  the  paranoid. 

The  predominant  mental  manifestations  in  dementia 
prsecox  may  be  those  of  depression,  of  excitement,  of 
stupor,  or  there  may  be  alternating  excitement  and  de- 
pression. It  is  not  unusual  to  find  the  attack  ushered 
in  by  feelings  of  vague  gloom  during  which  there  are 
perversions  of  sentiment,  a  lack  of  interest  in  the  af- 
fairs of  life,  disregard  for  the  feelings  of  friends  and 
family,  and  incapacity  for  mental  application.  A  storm 
of  excitement  may  succeed  to  this,  and  this  condition 
in  turn  be  followed  by  one  of  stupor.  In  excitement 
the  patient  is  disorderly  in  conduct,  erratic,  boastful, 


102  INSANITY. 

and  extravagant  in  conversation.  There  are  gran- 
diloquent delusions  and  suspiciousness.  Periods  of 
apparent  apathy  occur  during  which  the  patient,  if  be- 
lieving himself  unobserved,  is  watchful,  alert,  and 
observant  of  what  goes  on  about  him.  When  noticed 
and  questioned,  he  is  silent  and  unresponsive. 

Sudden  and  marked  fluctuations  in  the  emotional 
states  occur  and  constitute  to  my  mind  a  diagnostic 
feature  of  considerable  importance.  Depression  is  fre- 
quently of  shallow  depths  and  there  is  rapid  shifting 
to  exaltation.  It  is  difficult  to  take  seriously  a  state 
of  depression  such  as  was  observed  in  one  case,  in 
which  there  were  weeping,  lamentation,  fear  of  death, 
then  of  a  sudden  an  exclamation  "I  want  to  die,"  fol- 
lowed by  the  repeated  spelling  of  the  words  "d-i-e  die 
d-y-e  dye"  and  hysterical  laughter.  One  may  discount 
the  expression*  of  a  p'atient  who,  mentioning  the  un- 
pardonable sin  and  looking  for  death  in  consequence 
thereof,  laughed,  joked,  and  remarked  if  he  had  to  go 
to  hell  he  hoped  to  go  with  a  smile  on  his  face. 

In  the  hebephrenic  form  the  patient  develops  re- 
serve, shyness,  and  depression,  is  easily  embarrassed, 
shuns  company,  is  deeply  religious,  devotes  himself  to 
Bible  study,  is  fussy  in  dress,  spends  much  time  in  the 
bathroom  and  over  toilet  operations,  is  addicted  to  self- 
abuse.  Later  he  becomes  bombastic,  self-assertive, 
and  egotistic.  He  manufactures  universal  money;  is 
acquainted  with  astronomy.  From  one  state  the  pen- 
dulum swings  to  the  other.  The  patient  falls  to  brood- 
ing, consults  various  physicians,  reads  quack  advertise- 
ments, becomes  concerned  about  his  bodily  states  and 
the  loss  of  virility.  Delusions  of  a  religious  character 
develop.  These  may  be  of  the  nature  of  exaltation  and 


INSANITY.  103 

satisfaction  with  the  spiritual  state  or  may  be  self- 
accusatory.  Passages  in  the  Bible  are  read  and  ac- 
cepted by  the  individual  as  directed  to  him  personally. 
He  may  imagine  himself  a  second  Christ.  Some 
patients  believe  themselves  queens,  Virgin  Marys ;  un- 
married women  have  the  delusion  that  they  have  given 
birth  to  princes  and  kings.  Occasionally  the  passage 
in  Scripture  in  respect  to  the  offending  member  is 
given  a  direct  personal  application,  and  acts  of  self- 
mutilation  occur.  One  patient  whom  I  knew  destroyed 
her  eyes  by  broken  glass,  following  the  Scriptural  in- 
junction, "If  thine  eye  offend  thee  pluck  it  out  and  cast 
it  from  thee."  Another  cut  his  tongue  because  of  the 
feeling  that  he  said  things  that  he  ought  not.  Still 
another  made  numerous  transverse  gashes  on  his  nose. 
Another  removed  the  sexual  organs,  believing  that 
their  retention  was  inconsistent  with  a  religious  life. 
These  patients  are  sensational  in  manner  and  conversa- 
tion. They  do  sudden  motiveless  and  impulsive  acts, 
such  as  breaking  windows  or  crockery,  or  throwing 
themselves  into  shallow  water  with  apparent  suicidal 
intention.  One  will  remain  on  her  knees  indefinitely  in 
prayer.  With  this  hyper-religiosity  there  are  fre- 
quently eroticism  and  sexual  depravity.  One  may 
fancy  herself  engaged  or  married,  and  though  devoid 
of  personal  attractiveness  imagine  herself  sought  after 
in  society.  Another  believes  that  she  is  insulted  in 
thought.  One  fancies  she  has  a  hypnotic  influence 
over  black-eyed  persons,  and  imagines  herself  sub- 
jected to  the  sight  of  people  in  vulgar  situations.  A 
young  and  inexperienced  girl  may  say  and  do  shocking 
things  because  of  the  presence  in  mind  of  evil  sugges- 
tion. She  will  express  with  the  utmost  frankness  and 


104  INSANITY. 

unconcern  her  own  mental  states  and  converse  with- 
out shame  of  the  sexual  relation.  The  eroticism  and 
egotism  displayed  in  certain  of  these  cases  are  indi- 
cated in  the  following  leaf  from  a  patient's  auto- 
biography : — 

MY  DIARY. 

I  am  a  cynic  and  I  am  only  19.  So  there  must  be  something 
wrong  somewhere.  I  was  born  a  lady  and  of  good  social 
position,  but  whether  I  will  stick  to  my  traditions  or  not 
remains  to  be  seen.  I  have  had  more  experience  than  most 
girls  of  25.  I  have  been  abroad,  a  year's  travel  and  study  in 
France  with  a  French  governess  and  in  a  French  boarding 
school,  and  ten  months'  residence  in  Paris  and  almost  three 
months'  stay  in  Versailles.  I  have  had  four  proposals  and 
there  are  more  coming,  many.  I  do  not  flirt.  I  am  a  natural 
born  egotist,  cold,  impulsive,  fascinating  (so  every  one  tells 
me)  to  a  dangerous  (to  me)  degree — cynical,  heartless  (be- 
cause I  lost  mine  seven  years  ago  and  have  never  been  able 
to  regain  it),  indifferent  to  the  woe  I  cause  and  perfect  mis- 
tress of  the  situation  always.  That  is  the  brief  history  of  my 
life.  I  am  on  the  threshold  of  my  womanhood  and  hence  the 
reason  why  I  commence  my  diary. 

Well  I  am  in  love  to  begin  with  and  there  isn't  any  chance 
of  my  falling  out  so  far  as  I  can  can  see.  He  is  my  chum's 

Brother  and  his  nick-name  is  .  What  the  rest  is  you'll 

never  know.  Well  everything  comes  out  in  the  wash.  My 

mother  didn't  marry  until  she  was  32  and  to who  was  a 

widower  with  a  daughter.  They  both  had  pasts.  Mama  had 
fallen  in  love  with  a  man  whom  she  had  loved  for  five  years 
and  then  he  married  a  widow  with  money.  Father  had 

married  a and  she  had  gone  the  pace  and  eloped  with 

a  Jew  and  finally  landed  in  an  insane  asylum.  My  sister 

left  home  when  she  was  18  because  of  incompatibility  and 
lack  of  money.  We  were  paying  for  a  home.  Bien  c'est  mon 
tour  maintenant,  alors  je  partirai  pour  toujours  mais  en  pas- 
sant j'irai  a pour  rester  deux  mois  jusque  a  Noel. 

The  writings  of  other  patients  may  be  extremely  in- 
coherent, as  witness  the  following: — 


INSANITY.  105 

"Have  just  been  to  supper.  Did  not  knowing  what  the 
woodchuck  was  sent  me  here.  If  it  did  I  think  I  am  pretty 
well  prepared  to  prove  the  cause  of  it  and  I  learned  it  while 

in  P too     Oh  no,  I  had  forgotten  it  was  L that  told 

me  that  first  and  by  the  way  I  heard  some  one  say  that  the 
papers  reported  him  dead  and  I  afterwards  heard  it  disputed. 
I  will  have  to  dispute  myself  again  for  it  was  the  record  books 
being  carried  through  the  room  I  was  in  that  caused  me  to 
keep  a  record  of  the  way  I  was  being  worked." 

Another  writes: — 

July  26th  Flint  Mich 
Dear  Father 

Received  your  letter  yesterday  It  was  very  in- 
teresting I  spend  my  time  watching  the  squirrels. 
They  skin  the  cat  and  do  all  sorts  of  funny  things. 

Beth  is  here 

Lovingly 


The  following  productions  from  the  pen  of  a  woman 
in  middle  life,  the  subject  of  dementia  prsecox  and  in 
whose  case  there  has  been  during  a  decade  no  appre- 
ciable progression  toward  mental  impairment,  are  of 
more  or  less  interest : — 

MIRRORED  THOUGHTS. 

In  days  of  Old. 
Far  over  the  hills  of  Alaska 
Far  over  the  hills  of  Spain 
The  sun  sets  the  same  as  ours 
and  our  habits  are  about  the  same. 

We  read  and  consider  the  climate 
We  read  and  consider  the  scenes 
And  wondering  why  God  has  planted 
In  the  United  States  of  America. 


106  INSANITY. 

such  magazines  scenes 
Why  destruction  comes  into  our  Country 
Why  God  has  not  made  everything  beautiful 
All  Love  Harmony  Peace  and  Righteousness. 

There  will  be  no  Lightening  and  Thunder 
No  Cumbustibles  used  in  the  atmosphere 
There-  will  be  Harmonious  Music 
Into  the  clouds  and  everywhere 

In  days  of  Old  there  was  Noah 

We  lived  three  years  and  ten 

I  wonder  why  Doctors  dont  settle  the  climate 

and  live  it  over  again 


Kiss. 

Odious  act  Nectars  Kiss, 
Of  the  most  perfect  lips 
Natures  shame 
To  grace  this  world.    - 

With  such  a  heavenly  pretty  face 
Wildest  nymph  oh  woodland  elf 
Nature  made  thy  own  sweet  self 


BACHELOR  LOVE. 

Occasionally  indulging 
In  Light  Havannas 
And  chatting  affably 
Refreshing  Ideas 
Precision  and  Exactness 
Of  a  Bachelor 

His  mode  of  living 

His  accomplishments 

His  well   organized    Constitution 

His  Bashful  demeanor 


INSANITY.  107 

The  impediment  of  his  love 
It  is  reckoned  as  not  durable 
Is  refreshed  by  a  shower 
And  is  extinct  in  an  hour 

An  unmarried  woman  believes  herself  the  mother  of 
innumerable  children  conceived  in  the  hypnotic  state. 
There  are  superciliousness  and  inconsiderate  conduct 
toward  others.  Various  fears  and  obsessions  occur,  as 
that  of  infection,  or  loss  of  secretions  through  spots  on 
the  body.  One  applied  tan  shoe  polish,  banana  skins, 
and  apple' parings  to  the  surface  to  stop  this  loss.  This 
patient  answered  questions  by  signs  and  gestures,  op- 
posed dressing,  undressing,  and  exercise;  would  se- 
clude himself.  He  assumed  constrained  attitudes,  was 
apparently  indifferent,  but  often  smiled  at  amusing 
incidents.  He  had  delusions  of  conspiracy. 

Paroxysms  of  emotional  disturbance  occur,  such  as 
hysterical  and  inordinate  laughter,  squeezing  the 
throat,  making  guttural  noises.  One  patient  addicted 
to  these  practices  believed  he  was  secretary  to  the  devil 
and  had  clairvoyanjt  power.  One  restricts  herself  to  a 
certain  kind  of  diet.  One  hears  messages  in  the  tick- 
ing of  his  watch  and  fears  electrocution. 

Auditory  hallucinations  are  especially  frequent. 
Replies  to  questions  may  be  in  the  main  rational,  but 
there  are  interpolated  during  conversation  wholly  irrel- 
evant sentences :  Question.  "Are  you  of  German 
extraction?"  A.  "My  ancestors  were  English  and 
Swiss,  I  believe.  I  have  been  told  by  my  Aunt  Emma 
that  such  was  the  case.  You  see  she  always  had  a  nap 
in  the  afternoon,  but  I  might  say  that  my  father's 
name  is  English.  The  family  is  supposed  to  be  of 
English  descent.  There  is  a  little  Swiss  mixed  up  in 


108  INSANITY. 

it.  When  they  came  over  everyone  ate  a  cake  of  soap 
and  survived."  Q.  "They  didn't  explode  then  like  a 
geyser  when  they  put  a  cake  of  soap  in?"  A.  "No; 
they  survived." 

There  was  no  indication  of  appreciation  of  flying  the 
track  in  either  instance,  as  to  the  nap  in  the  afternoon 
or  the  cake  of  soap.  The  conversation  was  perfectly 
serious.  A  knowing  air  passed  across  his  face  when 
he  spoke  of  the  nap  in  the  afternoon  as  though  it  was 
rather  an  important  communication.  There  was  indi- 
cation of  appreciation  of  the  humorous  side  of  the  rela- 
tion of  the  cake  of  soap  and  the  geyser. 

Obsessions  of  words  which  may  be  based  upon 
sexual  experiences  in  early  life  are  tormenting  and  lead 
to  irritability  and  impulsive  acts  of  violence :  and  spite- 
ful remarks  addressed  to  other  people  are  in  some 
cases  interpretable  as  expressions  of  .self-censure. 
(See  chapter  on  "Symbolism  in  Sanity  and  in  In- 
sanity.") 

The  second  form,  the  katatonic}  has  much  in  com- 
mon with  the  hebephrenic.  The  distinction  between 
them  is  based  largely  upon  the  predominance  in  the 
katatonic  form  of  stuporous  states  and  of  muscular 
rigidity,  negativism  (disposition  to  oppose  and  to 
deny),  of  verbigeration  (the  repeating  over  and  over 
of  words  of  the  same  or  similar  sound),  of  imitative- 
ness  and  automatism.  The  patient  finds  himself 
checked  and  impeded  in  various  ways.  With  impulses 
to  do,  come  counter-waves  that  check  the  exercise  of 
the  will.  Patients  resist  attentions,  such  as  washing 
and  dressing,  bathing,  and  the  care  of  the  person. 
They  persistently  oppose.  One  may  wish  to  eat  and 
come  to  the  table  fairly  famished,  but  find  himself 


INSANITY.  109 

unable  to  carry  the  food  to  his  mouth.  One  avoids  a 
rug  in  which  there  is  a  slight  fold  and  steps  from  bare 
spot  to  bare  spot  on  the  floor.  During  dressing,  if  any- 
thing unusual  occurs,  the  garment  is  removed  and  the 
entire  process  recommenced.  Patients  may  complain 
of  feeling  light-headed  and  of  the  baneful  influence  of 
certain  other  people.  There  may  be  the  sensation  of 
falling.  One  patient  was  distressed  by  the  necessity 
for  turning  at  street  corners;  another  of  my  acquain- 
tance invariably  turned  back  one  or  more  times  after 
starting  from  any  point,'  and  was  anxious  to  com- 
municate her  thoughts,  but  after  a  few  words  was 
deterred  from  further  speaking.  Disrobing  operations 
begun  at  8.30  were  not  completed  until  11,  and  then 
the  struggle  came  whether  to  retire  or  write  letters. 
She  fancied  she  had  brought  a  curse  upon  the  hospital. 

One  patient  will  stand  for  hours  before  the  mirror, 
feeling  of  his  muscles.  Patients  imitate  the  attitudes, 
gestures,  and  speech  of  others.  With  katatonic  mani- 
festations more  pronounced  there  is  increased  apathy 
or  stupor.  The  patient  lies  in  bed,  the  head  drawn,  the 
limbs  tense,  the  eyes  closed,  attempts  to  move  him 
being  met  by  muscular  resistance ;  or  he  sits  for  hours 
in  a  constrained  position,  the  head  thrown  back,  saliva 
issuing  from  the  mouth,  and  unmindful  of  the  calls  ..of 
nature.  The  functions  of  the  bowels  and  bladder  are 
occasionally  arrested  by  voluntary  action  (negativism). 
Smearing  of  the  face  and  body  with  filth  is  also  en- 
countered. This  is  regarded  as  arising  from  perverted 
sexuality. 

The  paranoid  form  also  has  much  in  common  with 
the  hebephrenic.  The  predominant  note  in  these  cases 
is  of  egotism  and  boastfulness.  The  patient  believes 


110  INSANITY. 

himself  created  for  some  special  mission,  to  reform 
society,  to  promulgate  new  rules  for  dress  and  living. 
He  may  believe  himself  of  royal  birth  and  parentage. 
He  affects  carelessness  in  attire,  shows  indifference  to 
the  conventions,  and  advocates  a  return  to  the  classic 
costumes  of  ancient  times.  One  declines  to  take  his 
meals  with  hi's  family  because  of  the  feeling  of  su- 
periority. Impulsive  acts  of  violence  occur  and  the 
patient  may  be  dangerous  if  opposed.  Strange  acts  of 
which  the  patient  is  unable  to  give  any  explanation  are 
frequently  indulged  in.  One  whom  I  knew  started  out 
every  morning  early  for  a  five  or  six  mile  walk  through 
a  populous  portion  of  a  city  carrying  an  empty  tomato 
can  under  his  arm.  Another  caused  much  annoyance 
to  the  mail  carrier  by  filling  the  letter-box  with  buttons 
and  rubbish.  There  are  delusions  of  personal  prowess 
and  power,  in  some  cases  with  undue  attention  to  ath- 
letics and  the  eating  of  enormous  quantities  of  nitrog- 
enous food  with  the  idea  of  promoting  physical  de- 
velopment and  fitting  for  the  pugilistic  arena.  Patients 
believe  themselves  gifted  authors  or  authoresses.  One 
can  build  a  town  a  mile  high,  can  write  scientific  works 
in  various  languages,  is  to  be  a  commissioned  officer 
in  the  Queen's  army,  can  kill  himself  with  autosug- 
gestion, thinks  he  can  develop  an  additional  sense. 

One  patient  I  knew  remarked  that  although  Paganini 
compelled  the  worship  of  music-loving  people,  he  him- 
self would  not  be  satisfied  with  such  an  inglorious 
achievement.  "That  wouldn't  please  me — just  to  have 
worldly  people  worship  at  my  feet,"  he  said,  and  added : 
"Oh,  no,  what  I  desire  is  to  master  the  violin  suffi- 
ciently to  make  the  Lord  Almighty  God  kneel." 

One  of  my  patients  conceived  himself  to  be  a  second 


INSANITY.  Ill 

Christ,  and  had  delusions  against  the  Masons  and  Ro- 
man Catholics.  He  was  intensely  suspicious  and  once 
committed  an  assault  upon  another  who  was  whistling 
"Follow  the  Man  from  Cooks."  (He  was  from  Cook 
County,  111.)  This  patient  was  subject  to  violent 
paroxysms  of  weeping  over  the  deaths  of  eminent  men. 
Cases  which,  like  the  following,  embody  the  principal 
symptoms  of  both  the  hebephrenic  and  paranoid  form 
are  difficult  or  impossible  of  differentiation : — 

The  patient  was  26  years  of  age,  single,  of  tuberculous 
ancestry.  He  had  had  typhoid  fever  two  years  before.  He 
is  described  as  always  quiet  and  reserved ;  had  never  been 
about  much  with  other  people  and  had  held  himself  aloof, 
from  those  who  were  "common" — that  is  to  say,  he  did  not 
permit  close  contact,  but  had  done  church  and  settlement  work 
among  them  where  opportunities  for  patronizing  and  pseudo- 
philanthropy  came  into  play;  had  had  no  successful  continu- 
ous employment  since  leaving  college,  suffered  from  inflam- 
mation of  the  bile-duct  and  reached  a  melancholy  state.  He 
left  college  in  the  third  year  and  came  home  much  emaciated : 
could  not  retain  a  position  more  than  four  or  five  weeks ;  did 
not  like  the  competition  or  strife  of  business;  was  vacillating 
and  lacked  persistence.  Once  he  left  a  place  of  employment 
to  attend  to  the  wants  of  poor  children.  His  head  was  filled 
with  ideas  of  reform;  there  were  vagrant  impulses,  he  dis- 
appeared and  was  not  heard  of  for  a  long  time.  When  he 
returned  he  explained  that  he  had  been  to  see  the  country. 
He  had  remained  much  at  home,  having  the  feeling  that  there 
was  no  one  besides  himself  able  to  care  for  his  mother  and 
his  sister.  With  years  he  grew  more  and  more  peculiar  and 
eventually  reached  the  point  that  he  did  not  know  "what  he 
was  going  to  do  next."  He  talked  much  of  his  ancestry  and 
took  occasion  to  write  letters  asserting  the  excellent  family 
connection.  He  was  delicate  and  showed  exhaustion  after 
slight  exertion.  He  had  been  interested  in  psychical  research. 
Of  a  sudden  he  developed  the  fancy  that  he  should  be  more 
in  company  with  women  and  had  in  view  giving  sexual  atten- 


112  INSANITY. 

tion  to  a  housemaid.  Once  he  rapped  at  her  door  and  asked 
admission ;  being  denied,  he  'announced  that  he  would  come 
another  day,  and,  true  to  promise,  made  a  second  call.  In 
moral  self-questioning  about  this  episode,  he  consulted  the 
minister.  Later  he  announced  to  his  mother:  "You  wanted 
me  to  do  it" — and  claimed  that  he  had  been  influenced  to  the 
act  by  the  minister  and  another  person  as  well  as  herself.  He 
had  the  idea  that  people  communicated  with  him  by  signs  or 
waves;  that  his  mother's  brother  had  influenced  him;  that 
detectives  were  on  his  trail,  mistakenly  for  his  good.  There 
were  extreme  indecisions  and  he  frequently  spoke  of  being 
prevented  from  doing  what  he  desired.  When  his  brother 
told  him  he  must  go  away  from  home  for  care,  he  grew 
excited  and  antagonistic;  then  of  a  sudden,  as  is  frequently 
noted  in  these  cases,  his  manner  changed  and  he  gave  consent. 
Between  that  time  and  actual  departure,  he  blew  hot  and  cold 
on  the  subject.  He  averted  the  face  in  conversation,  was  con- 
fused and  found  it  difficult  to  express  his  thoughts ;  was 
introspective  and  had  misgivings;  was  undecided  as  to  what 
he  wanted  to  do  and  frequently  changed  his. mind;  had  the 
impression  that  certain  articles  of  food  disagreed  with  him. 

The  following  are  extracts  from  his  correspond- 
ence : — 

"Just  a  word.  When  you  were  here  I  did  not  have  a  very 
good  chance  to  talk  with  you.  I  have  been  leading  such 
things  as  have  been  going  on.  In  the  first  place,  I  am  no 

friend  of  .     He  has  lost  his  prestige,  his  power  in  , 

in  fact  he  is  a  dead  man.    ,  however,  is  a  gentleman.    The 

things  I  have  gone  through  in  the  last  month  were  enough 
to  drive  one  insane  and  as  a  student  of  mankind,  I  believe 
they  would  revolt  even  you.  His  family,  however,  are  all 
right.  But  the  end  is  not  yet.  You  see,  I  worked  three  years 

in  the with  Cousin ,  a  man  whom  everyone  respected 

and  loved.     is  bound  to  leave  this  world  as  and 

he  is  doing  all  he  can  to  promote  the  spirit.  You  see  he 
thinks  I  have  inherited  the  spirit  of  his  brother  and  whether 

I  will  or  not  be  as  bound  to  turn  into .    I  made  a  great 

mistake  in  not  taking  Mr.  Burr's  advice  and  going  to  him, 


INSANITY.  113 

telling  him  telling  him     Father  is  away  just  now  and  he  is 

doubly  active.     I   am  followed  by  or  watched  by  detectives 

whenever  I  am  down  town.    He  is  a  believer  in  bath  houses." 

"Just  a  word.    When  you  were  here,  I  did  not  have  a  very 

good  chance  to  talk  with  you.    I  am  not  a  friend  of who 

had  but  a  few  more  months  to  live.  He  is  a  believer  in  family 
and  that  is  what  he  is  living  for  just  now  apparently.  The 

reign  of  terror  is  over.    is  a  gentleman.    Was  sorry  not  to 

see  your  mother  before  she  went  to  —  -  as  I  wanted  to  help 
her  in  case  there  was  anything  she  wanted  down  town.  How 
is  everything  now — .  I  was  sorry  not  to  hear."  . 

Discharged  from  Oak  Grove,  placed  in  another  in- 
stitution, thence  discharged,  he  wrote  as  follows  on 
March  15th:— 

Dr.  C.  B.  Burr, 

Oak  Grove  Sanitarium, 

Flint,  Mich. 
Dear  Doctor  Burr: — 

I  know  that  you  are  still  taking  some  interest  in 
me  and  I  thank  you  for  it.  Were  it  not  for  the  fact 
that  my  heart  does  not  stay  in  the  right  place  I  am 
sure  that  I  could  be  a  gentleman  in  spirit.  Some 
mornings  my  circulation  goes  down  and  my  heart 
beats  so  feebly  that  the  suffering  is  intense.  Any  ex- 
ercise sends  the  pulse  the  wrong  way. 

I  realize  that  my  condition  is  not  good  yet  I  try 
to  keep  my  mind  on  reading  and  other  forms  of 
mental  exercise  and  I  thank  you  for  the  help  you  have 
given  me  to  do  this.  Respectfully  yours . 

And  as  follows  on  March  22d : — 

Dr.  C.  B.  Burr, 

Oak  Grove  Sanitarium, 

Flint,  Mich. 
Dear  Sir 

Please  forget  me  altogether.  I  get  into  a  run 
down  condition,  feel  your  impulses  and  am  weak 

enough  to  believe  I  can  keep  them  . 

8 


114  INSANITY. 

Another  writes  as  follows : — 

June  15 
1913. 
My  dear  Dr.  Burr: — 

After  the  Red  White  and  Blue  I  am  weak  and 
faint  —  and  so  —  so  exhausted  —  I  can  not  get  — 
my  breath  —  please  —  wont  you  have  —  have  —  Dr. 
—  send  some  thing  to  relieve  me  —  also  please  ask 
him  to  call  upon  me  —  this  afternoon  when  on  this 
floor. 

Very  truly  yours 

/  do  not  know. 

Sunday  X 

Further  writings  of  the  same  patient  illustrate 
stereotypy : — 

Please  please  please  may  I  have  Miss for  my 

special  nurse?  I  am  so  frightened  —  tonight  —  or 
wont  —  wont  you  please  —  come  —  and  give  —  me 
a  hypo? 

Freud  has  analyzed  a  most  interesting  case  of  de- 
jnentia  prsecox  showing  the  hysterical  groundwork. 
Not  a  few  cases  present  themselves  which  have  at 
some  period  of  their  progress  offered  suggestions  of 
hysteria.  Indeed,  the  katatonic  and  less  markedly 
stuporous  states  may  mislead  the  observer  into  a  diag- 
nosis of  this  disorder.  In  any  event,  given  hysterical 
phenomena  in  the  early  period  of  a  suspected  dementia 
prsecox,  a  search  for  the  complex1  may  be  abundantly 
rewarded. 

One  believes  that  allusions  to  public  characters  in 
the  daily  press  point  to  himself ;  that  legislation  is  for 
his  sole  bene'fit ;  that  theatrical  performances  are  put  on 
for  his  edification  exclusively ;  that  locomotive  whistles 

1  See  chapter  on  Hysteria. 


INSANITY.  115 

call  him,  and  that  gestures  of  others  are  directed  to- 
ward him. 

Prognosis. — Certain  cases,  despite  the  designation 
of  the  disease,  seem  to  recover.  Others  improve  to  an 
extent  which  is  indicative  of  complete  recovery.  One 
in  particular  in  my  acquaintance  so  far  recovered  in 
appearance  that  he  was  pronounced  sane  by  the  courts, 
invested  with  .the  care  of  his  property,  which  he  turned 
over  to  the  keeping  of  others,  subsequently  involving 
a  long  and  expensive  litigation.  He  relapsed  in  two  or 
three  months  and  has  since  been  in  an  insane  condition. 
In  the  vast  majority  of  cases  there  is  mental  deteriora- 
tion, either  steadily  progressing  or  slowly  taking  place, 
there  being  intervals  of  composure  and  relative  dis- 
comfort. 

Treatment. — General  principles  for  the  care  of  the 
chronic  insane  govern  the  treatment  of  cases  of  demen- 
tia prsecox.  The  nutrition  must  be  kept  up  by  attention 
to  elimination,  tonics,  and  ample  feeding.  Owing  to 
delusions,  the  disposition  to  oppose,  and  the  inhibition 
which  the  disease  places  upon  the  conduct  of  the  pa- 
tient, there  is  occasional  refusal  of  food  to  the  extent 
that  mechanical  feeding  is  necessary.  The  bowels 
should  be  kept  regular  by  laxatives  as  they  can  be  ad- 
ministered, and  by  enemas.  Owing  to  the  fact  that  in 
certain  katatonic  cases  there  is  voluntary  retention  of 
urine,  especial  care  should  be  exercised  that  bladder 
distention  does  not  proceed  to  a  dangerous  degree.  The 
Russian  bath  and  salt  glow,  the  cold  shower  with  sub- 
sequent friction,  massage  and  passive  exercise  of  joints 
which  are  habitually  held  by  the  patient  in  constrained 
positions,  are  all  of  value.  The  warm  bath  of  several 
hours'  duration  has  a  calmative  and  beneficial  effect 


116  INSANITY. 

in  periods  of  excitement.  Exercise  out  of  doors  should 
be  regularly  given,  although  the  disposition  of  the  pa- 
tient not  to  do  may  demand  in  some  instances  the  ex- 
hibition of  force.  Whatever  light  employment  he  may 
be  induced  to  take  will  be  found  of  service. 

Paralytic  Dementia. 

Synonyms :  Paretic  Dementia,  General  Paralysis  of 
the  Insane,  General  Paresis. 

This  is  a  disease  displaying  slowly  increasing  mental 
impairment,  disorders  of  muscular  movements,  gastric 
and  other  nervous  crises,  disturbance  of  the  higher  re- 
flexes (inco-ordination),  and  mental  and  physical  de- 
cay. It  is  a  disease  of  adult  life  and  observed  chiefly 
in  those  whose  habits  have  been  irregular,  who  have 
been  addicted  to  excesses  of  various  kinds,  who  have 
had  syphilis,  who  have  been  steady  drinkers,  or  who 
from  one  cause  or  another  have  exhausted  their 
nervous  force.  Syphilis  is  believed  by  many  to  enter 
into  the  causation  of  at  least  75  per  cent,  of  cases,  and 
there  are  those  who  regard  it  practically  the  exclusive 
cause.  The  disease  attacks  those  of  high-strung 
nervous  organization,  intellectual  men,  men  of  affairs, 
those  accustomed  to  working  at  high  pressure.  It  was 
scarcely  known  among  women  thirty-five  years  ago, 
but  of  late  is  more  and  more  frequently  encountered. 
It  is  a  disease  of  middle  life,  but  occasionally  occurs  in 
those  advanced  in  years.  It  develops  many  years  after 
syphilitic  infection  and  was  formerly  supposed  to  be 
due  to  nutritional  and  toxic  disturbances,  the  remote 
effect  of  the  original  infection.  Recently  the  living 
spirochsetse  of  syphilis  have  been  discovered  in  the 
brain  matter.  There  is  a  juvenile  type. 


INSANITY.  117 

The  disease  is  pathologically  a  meningo-encephalitis. 
There  exist  degeneration  of  the  cortex  of  the  brain  and 
a  low  grade  of  inflammation  of  the  cortex  and  mem- 
branes. Adhesion  of  the  pia  mater  to  the  cortex  is 
found  post-mortem,  and  a  roughened,  worm-eaten  ap- 
pearance of  the  cortex  results  from  attempts  to  sepa- 
rate the  pia  mater  therefrom. 

A  patient  breaking  down  with  paretic  dementia  is  at 
first  visionary  and  erratic.  He  is  full  of  pleasurable 
sensations,  there  is  an  early  period  of  mental  exaltation 
and  marked  change  in  emotional  tone.  While  com- 
fortable if  left  to  follow  his  own  devices,  he  is  irritable 
if  opposed.  He  has  large  ideas  of  business,  entertains 
impracticable  schemes,  and  perhaps  loses  the  accumula- 
tions of  a  lifetime  in  unwise  business  ventures  or  un- 
profitable investments  or  dissipates  them  in  extravagant 
purchases.  He  gives  but  indifferent  thought  to  his 
business  and  is  utterly  unable  to  fix  attention  upon  its 
details.  He  is  careless,  inconsiderate,  and  fails  to  keep 
business  appointments.  His  handwriting  becomes  ir- 
regular and  he  drops  words  from  sentences  and  letters 
from  words.  When  executing  the  finer  movements  of 
the  face  and  fingers  he  shows  lack  of  precision.  Hesi- 
tation and  thickness  of  speech  early  occur,  giving  to 
those  unaware  of  his  breaking  down  an  impression  that 
he  is  drinking  to  excess.  Disorders  of  the  iris,  inequal- 
ity of  the  pupils,  pin-hole  or  immobile  pupils  are  pres- 
ent. There  is  frequently  a  lack  of  respect  for  the 
rights  of  property  and  appropriation  of  what  comes 
within  reach  under  the  misapprehension  that  it  belongs 
to  the  patient.  The  feelings  are  easily  stirred,  delu- 
sions develop  and  grow  more  and  more  extravagant  as 
muscular  inco-ordination  and  debility  increase.  The 


118  INSANITY. 

patient  believes  himself  possessed  of  thousands  of 
millions ;  that  he  is  the  strongest  man  in  the  world ;  that 
he  can  set  out  worlds  in  the  heavens;  that  he  is  the 
vicegerent  of  God,  or  God  Himself;  that  train-load 
after  train-load  of  diamonds  are  coming  to  him  direct 
from  the  mines;  that  he  owns  all  the  banks  and  the 
finest  houses  and  fleetest  horses;  that  in  order  to  fly 
all  that  is  necessary  is  to  make  the  first  attempt.  One 
patient  whom  I  knew  took  position  on  the  sill  of  a 
second-story  window  and  was  about  to  take  flight  when 
intercepted.  Nothing  can  exceed  the  extravagant  ex- 
pression in  these  cases.  I  once  heard  a  patient  say  that 
God  had  told  him  that  in  case  of  any  difference  of 
opinion  between  Himself  and  the  patient,  the  latter 
should  "have  the  say."  Another  made  occasional  ex- 
cursions to  the  sun  and  put  copper  clamps  about  it. 

Patients  suffering  from  paresis  are  rarely  irritable 
unless  opposed  or  thwarted  in  their  undertakings,  but, 
inasmuch  as  interference  with  many  of  their  projects 
is  unescapable,  friction  is  with  difficulty  avoided. 
They  are  altruistic,  philanthropic,  are  universal  in  their 
sympathies,  and  cheerfully  share  their  property  with 
all  with  whom  they  come  in  contact.  One  having  read 
a  newspaper  account  of  the  loss  on  the  part  of  Russell 
Sage  of  $5,000,000,  proposed  to  another  to  reimburse 
him  with  a  check.  "Oh,  make  it  $10,000,000,"  the 
second  replied. 

A  friend  told  me  of  the  delusions  of  John,  a  paretic 
patient  who  thought  that  he  had  died  and  that  his  soul 
had  visited  heaven  and  hades.  Deeply  imbued  with 
many  peculiar  religious  notions,  he  never  lost  an  op- 
portunity to  attend  chapel  services  and  invariably  sat 
in  the  front  row  of  the  congregation.  One  Sabbath, 


INSANITY.  119 

when  so  placed,  the  officiating  clergyman  had  selected 
as  a  text  that  portion  of  the  Book  of  Revelations  de- 
scriptive of  heaven  and  the  glories  thereof.  Suddenly, 
just  as  he  was  in  the  midst  of  a  glowing  portrayal  of 
the  jasper  walls,  pearly  gates,  and  golden  streets,  up 
jumped  John  and  at  the  very  top  of  his  voice  bawled 
out:  "You  don't  know  a  thing  about  it.  I've  been 
there  myself." 

A  paretic  in  a  Southern  asylum,  expecting  to  be 
elected  President  of  the  United  States,  was  preparing 
his  Cabinet  and  parceling  out  the  different  offices  to 
his  friends.  A  Georgia  cracker  was  looking  on  intently 
as  if  present  at  some  epoch-making  gathering.  Some 
one  present  asked  the  paretic  patient  if  he  would  not 
give  C.  .some  important  office.  Whereupon  he  replied, 
"I  will  make  him  Minister  to  Russia."  A  look  of  as- 
tonishment spread  over  C.'s  face  and  he  exclaimed: 
"Good  Lord,  I  can't  preach  in  my  own  country  yet!" 

There  is  in  many  instances  increased  sexual  excite- 
ment and  the  patient  believes  himself  the  progenitor 
of  families  of  thousands.  As  time  goes  on  the  condi- 
tion of  the  pupils  becomes  more  uniform,  either  habit- 
ually unequal  or  contracted  to  the  pinhole  point. 
There  is  often  a  glassy  appearance  of  the  cornea.  The 
pinhole  pupil  is  more  often  encountered  in  cases  of 
the  neurasthenic  or  depressed  type  than  in  those  where 
the  emotional  tone  is  one  of  exaltation.  From  bad  to 
worse  the  patient's  condition  goes  on,  with  occasional 
periods  of  remission.  Seizures  of  an  epileptiform  or 
apoplectiform  character  occur.  Epileptiform  seizures 
may  come  in  series  or  separately,  and  following  them 
are  transitory  local  paralyses.  Apoplectiform  seizures, 
as  the  word  implies,  are,  as  a  rule,  followed  by  paraly- 


120  INSANITY. 

sis  of  one  side  of  the  body  and  face,  which,  due  to  local 
pressure  from  effusion  into  the  brain,  clears  up  more 
or  less  completely  after  a  few  days.  Death  may  come 
suddenly  from  a  severe  seizure,  but  oftener  follows  as 
a  result  of  slow  exhaustion  after  a  tedious  period  of 
confinement  to  bed  during  which  bedsores,  dependent 
upon  lack  of  nutrition  of  the  skin,  develop.  Arrest  in 
the  active,  progress  of  the  disease,  or  remissions,  may 
take  place,  and  a  deceptive  appearance  of  permanent 
improvement  may  be  present.  While  quiet,  no  longer 
entertaining  delusions,  and  having  the  appearance  of 
good  general  health,  patients  in  remission  show  pro- 
nounced emotional  instability  and  incapacity  for  busi- 
ness. Occasionally  the  improvement  or  remission 
seems  to  be  determined  by  the  existence  of  a  large, 
sloughy  bedsore.  Attention  is  called  to  the  hand- 
writing of  a  patient  in  whom  improvement  occurred 
after  an  extensive  slough.  Toward  the  close  of  life  the 
patient  requires  the  same  degree  of  attention  as  a  little 
child,  but  so  long  as  consciousness  remains  there  is  a 
feeling  of  strength  and  power.  Anaesthesias,  choking 
from  paralysis  of  the  throat,  and  paralysis  of  the  blad- 
der, which  may  result  in  overdistention  and  rupture, 
are  symptoms  encountered  from  time  to  time,  and 
should  be  especially  guarded  against.  There  is  often 
extreme  friability  of  bones,  and  fractures  occur  from 
muscular  action  or  trifling  accident.  Two  patients 
whom  I  had  under  care  fractured,  one  the  femur,  the 
other  the  tibia,  through  turning  around  suddenly.  The 
movement  was  clumsily  made  in  consequence  of  mus- 
cular inco-ordination  and  the  bone  snapped.  In  exalted 
cases  the  expression  "first-rate"  is  frequently  employed 
in  reply  to  inquiries  as  to  health,  and  has  been  called 


INSANITY. 


121 


LA 


*. 


June  22,  1881.    In  June  an  extensive  and  indolent  slough 
appeared  ou  heel. 


August  18,  1881. 


122  INSANITY. 

the  "verbal  formula  of  a  hopeless  malady."  Periods 
of  furious  and  unreasoning  excitement  are  apt  to  oc- 
cur. In  these,  fortunately  of  brief  duration  as  a  rule, 
the  patient  loses  all  self-control,  commits  assaults, 
throws  himself  about,  grates  his  teeth,  and  is  noisy  and 
extremely  destructive.  Injuries  from  falls  are  espe- 
cially prone  to  produce  hsematoma  auris  (see  page 
194,  Othematoma). 

The  above  are  the  more  frequent  manifestations  of 
paretic  dementia.  Occasionally,  however,  the  symp- 
toms are  those  of  extreme  depression,  and  then  there 
is  an  intensity,  an  exaggeration,  so  to  speak,  of  depres- 
sion, which,  taken  in  connection  with  the  physical  signs, 
assists  the  observer  in  differentiating  the  condition 
from  the  depressive  insanities  and  from  the  disease 
with  which  it  is  more  often  confounded,  neurasthenia. 
Change  in  the  personality  occurs,  there  is  indisposition 
for  exertion ;  painful  sensations  in  the  back  and  ex- 
tremities are  complained  of  and  vasomotor  disturbances 
are  present.  In  paretic  dementia  of  this  type  there 
may  be  absence  of  delusions  apart  from  those  referable 
to  the  bodily  states.  Delusions  of  unworthiness  such 
as  those  observed  in  melancholia  are  not  present,  but 
there  may  be  a  feeling  of  so  great  ennui  as  to  lead  to 
suicidal  determination  and  indeed  suicidal  attempts. 
Constipation  and  inactive  liver  are  present.  All  sorts 
of  hypochondriacal  fancies  based  upon  disturbances  of 
organic  sensation  occur.  There  is  pupillary  contrac- 
tion or  inequality,  and  occasionally  the  pupil  is  of  the 
Argyll-Robertson1  type.  "Think  twice,"  says  Berkley, 
"before  contenting  yourself  with  a  diagnosis  of  neu- 


1  Showing  accommodation  to  distance,  but  not  to  light. 


INSANITY.  123 

rasthenia  in  a  man  or  a  woman  who  in  middle  life 
shows  well-defined  reflex  pupillary  disturbance.  The 
prognosis  is  ominous."  In  paretic  dementia  of  the 
melancholic  quality  there  is  outwardly  less  disturbance 
of  the  motor  co-ordination,  this  owing  to  the  fact  that 
the  patient's  life  is  inactive  and  the  symptoms  of  ataxia, 
always  aggravated  by  fatigue,  less  in  evidence.  When 
the  patient  moves  about  it  is  usually  in  obedience  to 
requests  and  with  conscious  exercise  of  co-ordination. 
A  case  cited  by  Berkley  forcibly  illustrates  the 
danger  of  mistaken  diagnosis.  Speaking  of  a  patient 
in  whom  transient  irascibility  and  a  tendency  to  f  orget- 
f ulness  occurred,  these  symptoms  followed  by  an  emo- 
tional state  and  incomplete  paralysis  of  the  left  internal 
rectus  (for  which  cutting  of  the  muscles  was  advised 
by  an  oculist),  he  says:  "The  course  was  now  from 
bad  to  worse.  The  emotional  state  reached  such  a 
pitch  that  the  patient  became  hypochondriacal,  and  was 
sent  by  his  family  physician  to  consult  with  a  medical 
man  of  note.  A  diagnosis  of  'neurasthenia'  was  made, 
and  the  patient  was  treated  accordingly,  only  with  the 
result  that  the  progress  downward  became  more  and 
more  rapid.  In  the  spring  of  1899  mental  symptoms 
of  a  character  to  alarm  his  family  supervened,  and  the 
case  came  to  me  for  consultation.  A  diagnosis  of  de^- 
mentia  paralytica  at  about  the  beginning  of  the  second 
stage  was  made,  and  the  family  were  warned  of  the 
progress.  A  few  days  later  the  man  became  maniacal, 
attempted  to  kill  several  persons,  and  probably  would 
have  succeeded  in  doing  so  had  not  all  deadly  weapons 
been  removed.  I  elicited  a  history  of  syphilitic. infec- 
tion ten  years  previously,  and  also  of  former  excesses 
in  alcohol." 


124  INSANITY. 

Summing  up,  he  pithily  adds :  "Here  was  an  almost 
typical  case  of  progressive  paralysis,  showing  all  the 
cardinal  symptoms  of  the  disease,  yet  at  a  time  when 
treatment  might  have  been  cf  some  avail  it  was  not 
recognized.  In  fact,  the  procedures  advised,  far  from 
benefiting  the  patient,  were,  if  anything,  calculated  to 
do  harm." 

In  depressed  cases  the  diagnosis  is  often  further 
complicated  by  a  neuralgic  condition,  the  so-called 
gastric  crisis,  too  frequently  diagnosticated  as  gastral- 
gia  from  local  causes.  Attacks  come  on  at  occasional 
intervals  without  obvious  cause.  The  pain  is  exquisite 
and  there  is  at  times  vomiting.  The  organic  memory 
and  organic  sensation  are  disturbed,  particularly  in 
the  depressed  type,  and  the  belief  is  called  into  exist- 
ence that  a  portion  of  the  organism  is  dead  or  that  the 
body  is  all  gone.  Self-mutilatory  acts  are  sometimes 
committed  because  of  the  feeling  that  a  member  is 
worthless  and  should  be  out  of  the  way.  Such  cases 
as  these  lacking  the  one  element  which  is  present  in 
the  other  class,  namely,  that  of  good  feeling,  are 
pitiable  in  the  extreme. 

Differential  Diagnosis. — The  differential  diagnosis 
from  the  condition  of  pseudo-paresis,  the  result  of  pro- 
longed alcoholic  indulgence,  is  in  some  instances  diffi- 
cult. In  both  conditions  there  are  apt  to  be  extravagant 
delusions,  the  oculomotor  symptoms,  fibrillary  tremor 
of  the  tongue,  ataxic  gait,  exaggerated  reflexes,  and  the 
phenomena  of  epileptiform  seizures.  A  careful  study 
of  the  etiology  of  the  case  will  go  far  to  clear  up  the 
diagnosis  or  at  all  events  influence  the  diagnostician 
to  withhold  judgment  until  the  results  of  treatment  for 
a  limited  period  of  time  can  be  ascertained.  The  symp- 


INSANITY.  125 

toms  of  pseudo-paresis  due  to  alcohol  will,  as  a  rule, 
change  materially  within  four  or  six  weeks  of  quiet, 
the  withdrawal  of  the  habitual  stimulant,  the  use  of 
hydrotherapy,  employment  of  cardiac  and  general 
tonics,  restraint,  and  the  hospital  or  sanitarium  regime. 
I  have  in  mind  at  present  two  cases  in  which  the  resem- 
blance to  paretic  dementia  was  so  strong  as  to  lead  to 
the  diagnosis  of  the  latter  condition.  In  one  there 
were  delusions  of  the  most  extravagant  type,  the  pin- 
hole  pupil,  indistinctness  in  articulation,  visceral  delu- 
sions, and  marked  ataxia  in  gait  and  speech.  Regis 
says  that  inequality  of  the  pupils  is  scarcely  ever  lack- 
ing in  alcoholic  pseudo-general  paresis,  and  that  per- 
manent hemiplegia  and  aphasia  are  more  frequent  and 
more  persistent  than  in  true  paresis.  The  pupillary 
aperture  is  often  misshapen,  the  pupil  is  dull  and 
cloudy,  and  visual  acuteness  is  lost  in  the  alcoholic 
type.  In  the  remissions  of  general  paresis,  pupillary 
inequality  is  one  of  the  first  symptoms  to  disappear, 
while  the  embarrassment  of  speech  remains  in  a 
greater  or  less  degree.  The  reverse  is  true  of  alcoholic 
paresis. 

The  recognition  of  doubtful  cases  of  paretic  demen- 
tia in  early  stages  has  been  simplified  in  recent  years 
by  blood  and  spinal  fluid  examination.  If  a  so-called 
positive  Wassermann  reaction  is  obtained  from  the 
blood  the  pre-existence  of  syphilis  is  indicated  and  is 
to  that  extent  conclusive  as  to  a  causative  factor.  In 
recent  and  possibly  curable  cases  of  cerebrospinal 
syphilis  the  Wassermann  is  less  uniformly  positive 
than  in  paretic  dementia,  a  so-called  parasyphilitic1 

1  It  has  been  demonstrated  by  recent  investigators  studying 
the  brains  of  those  suffering  from  paretic  dementia  that  there 


126  INSANITY. 

disease.  The  Wassermann  blood  test  requires  special 
apparatus  and  nicety  of  manipulation  and  can  be  suc- 
cessfully made  only  in  a  clinical  laboratory  or  by  one 
skilled  in  chemistry  and  having  the  necessary  equip- 
ment. As  to  the  examination  of  fluid  obtained  by 
puncture  of  the  spinal  canal  in  the  lumbar  region,  if 
this  should  show  the  presence  under  the  microscope  of 
more  than  a  very  few  lymphocytes1  or  of  numerous 
plasma  cells  of  large  size,  the  result  of  the  examina- 
tion would  be  highly  confirmatory  of  any  well- 
grounded  suspicion  of  paretic  dementia  based  upon 
psychical  and  bodily  symptoms. 

Stearns  says  that  in  alcoholic  paresis  delusions  of 
grandeur  are  persistent,  and  rarely  change,  while  in 
true  paresis  these  ideas  change  from  day  to  day  with- 
out order  or  consistency.  He  also  says  that  the  diffi- 
culty in  pronunciation  of  certain  words  and  sentences 
is  greater,  and  the  fibrillary  tremor  more  limited  in 
general  paresis  than  in  the  other  condition.  In  both, 
epileptiform  seizures  and  local  anaesthesias  occur,  but 
in  alcoholic  paresis  hallucinations  of  sight  and  sensory 
disorders  are  more  marked  than  in  paresis.  In  alco- 
holic paresis  the  patient  frequently  suffers  from  gastric 
catarrh  and  loss  of  appetite,  while  a  ravenous  appetite 
is  almost  an  invariable  accompaniment  of  true  pare.tic 
dementia. 

Bevan  Lewis  says  that  motor  impotence,  not  inco- 
ordination  or  ataxy,  is  the  distinctive  feature  of  alco- 


are  present  in  these  the  living  spirochsetae  of  syphilis.  The 
trend  of  thought  at  the  time  of  this  revision  is  toward  aban- 
doning the  designations  meta-  and  para-  syphilitic. 

1  Lymphocytes    and   plasma    cells    are    constituents    of   the 
blood,  and,  in  small  numbers,  of  the  spinal  fluid  also. 


INSANITY.  127 

holism  of  the  motor  sphere  of  the  cerebrum.  The 
earliest  indication  of  this  is  usually  a  notable  degree 
of  fine  muscular  tremor,  implicating,  in  the  first  place, 
the  fingers  and  hand,  and  gradually  spreading  to  the 
arm ;  in  the  next  place,  involving  the  tongue,  lips,  and 
articulatory  muscles  generally,  and,  lastly,  extending 
to  the  foot  and  leg.  The  tremor  is  always  more 
marked  in  the  morning  and  may  be  dissipated  by  a 
glass  of  spirits ;  if  at  first  not  obvious,  it  may  often  be 
brought  out  by  prolonged  extension  of  the  arm,  any 
slight  voluntary  exertion  tending  to  establish  it. 

The  depressed  form  may  be  differentiated  from 
neurasthenia  by  the  presence  in  paresis  of  motor  symp- 
toms referable  to  the  eye  and  of  impairment  of 
memory. 

Psychological  Analysis : — 

Sensations-Sit  first  lively,  later  slow — may  be  abol- 
ished. 

Perception  false.  Hallucinations  or  Illusions  at 
times  present. 

Memory  hopelessly  impaired. 

Organic  Memory  impaired.  Personality  totally 
changed. 

Ideation  feeble,  irregular. 

Reasoning  and  Judgment  progressively  impaired. 
Grandiose  delusions. 

Emotions,  as  a  rule,  exalted  and  pleasurable;  some- 
times extremely  depressed. 

Will  impaired ;  inhibitory  control  impaired  and  lost ; 
higher  cerebral  reflexes  impaired  and  lost.  The  atten- 
tion is  fixed  with  difficulty. 

Physical  Symptoms. — Progressive  loss  of  ability  to 
use  the  voluntary  muscles  (inco-ordination  of  move- 


128  INSANITY. 

ment)  ;  change  in  pupils;  constipation  or  diarrhoea; 
enormous  appetite ;  lack  of  control  over  the  bowels  and 
bladder;  retention  of  urine;  cystitis;  bedsores;  fragil- 
ity of  bones;  convulsions  or  apoplectiform  attacks. 

In  Paretic  Dementia  there  is,  as  a  rule,  no  tendency 
to  suicide,  but  self-mutilation  may  occur,  in  the  belief 
that  a  dead  or  offending  member  should  be  removed. 
Suicidal  impulses  are  present  in  occasional  cases. 

The  homicidal  tendency  is  encountered  but  rarely. 
One  patient  planned  to  crush  another's  head  in  a  door. 
Another  choked  a  nurse  to  the  verge  of  complete 
asphyxia.  Habits  careless  from  the  first,  and  toward 
the  close  of  the  disease  untidy  and  degraded. 

Termination. — Death. 

Treatment. — No  hope  of  recovery  and  little  hope  of 
permanent  amelioration  may  be  held  out  in  this  disease. 
Although  syphilitic  etiology  may  be  established  beyond 
peradventure  of  doubt,  direct  specific  medication  is  not 
often  found  to  be  of  curative  value.  The  only  possi- 
bility of  a  relief  of  the  condition,  however,  lying  in  an 
antisyphilitic  regime,  the  use  of  the  iodide  of  potas- 
sium is  at  least  in  the  earlier  stages  advisable,  perhaps 
demanded.  The  patient  should  have  care  away  from 
home  to  a  well-appointed  hospital  or  sanitarium  where 
non-irritating  restraint  and  control  may  be  exercised, 
the  patient  prevented  from  squandering  his  means  and 
from  disgracing  or  discrediting  himself  or  his  family 
by  acts  prompted  by  the  morbid  condition.  The  rou- 
tine life  of  the  hospital,  hydrotherapy,  and  exercise 
suited  to  the  capacity  and  strength,  careful  regulation 
of  diet,  attention  to  elimination,  and  the  absence  of 
exciting  or  disturbing  influences  frequently  bring  about 
a  prolonged  remission  in  the  disease.  The  disease  proc- 


INSANITY.  129 

ess  seems  to  be  arrested  and  the  patient's  condition 
remains  for  months  very  comfortable.  It  is  yet  too 
early  to  speak  of  the  efficacy  of  the  Swift-Ellis  intra- 
spinal  salvarsanized  serum  treatment,  of  late  in  vogue. 
Sleep-producing  agents  are  often  needed  and  of  these 
the  most  generally  available  and  best  borne  are  chloral 
hydrate  and  the  bromides.  These  remedies  in  doses  of 
20  to  25  grains  of  the  former  and  20  grains  of  the  latter 
are  valuable  in  the  distressing  complication  of  epilepti- 
form  seizures  and  act  satisfactorily  by  the  rectum 
when  their .  administration  by  the  mouth  is  impracti- 
cable. In  but  one  instance  have  I  ever  discovered  any 
contraindication  to  their  employment.  In  that  case, 
one  of  the  depressed  and  asthenic  type  with  remarkable 
insight  into  the  condition,  there  resulted  collapse — 
not  once  only,  but  twice  or  thrice,  until  the  relation 
of  the  symptom  to  chloral  and  bromide  ingestion  was 
indubitable. 

Juvenile  Paresis. 

A  form  of  paretic  dementia  affecting  the  young 
(Juvenile  Paresis)  was  described  by  Clouston,  in  1877, 
and  in  recent  years  has  been  brought  plainly  to  atten- 
tion by  Kraepelin  and  his  school.  It  develops,  as  a 
rule,  at  or  about  the  pubescent  age,  but  in  some  cases 
at  as  early  a  period  as  the  fifth  or  sixth  year.  The 
existence  of  syphilis,  naturally  in  the  vast  majority  of 
these  patients  inherited,  is  brought  definitely  to  light 
through  the  Wassermann  reaction  and  examination  of 
the  spinal  fluid.  A  case  at  one  time  under  the  author's 
observation  presented  the  following  symptoms: — 

She  was  said  to  have  been  bright  in  school  in  very  early 
childhood,  but  at  the  age  of  12  gradually  grew  dull  and  could 


130  INSANITY. 

not  master  her  studies.  Because  of  deficiencies  she  was  not 
popular  with  her  associates  and  became  extremely  sensitive. 
She  did  not  enter  into  sports  with  those  of  her  age  and 
experienced  much  distress  because  she  lacked  attractiveness  to 
those  of  the  opposite  sex.  At  the  age  of  22  there  occurred  a 
hysteroidal  attack  during  which  she  opposed  attentions,  could 
not  be  persuaded  to  go  to  bed,  displayed  purposeless  activity, 
suffered  from  insomnia,  talked  constantly,  and  was  repetitious. 
A  year  later  an  attack  attended  by  muscular  tremor  occurred. 
She  could  not  feed  herself,  was  ataxic,  and  subject  to  falls. 
These  symptoms  slowly  increased.  There  developed  drooping 
of  the  eyelids,  stammering  and  tremulous  speech,  great  emo- 
tional disturbance,  and  confusion.  There  was  frequent  outcry 
to  "go  somewhere"  and  she  repeated  over  and  over  "Don't 
leave  me  alone,"  "I  want  my  clothes,"  "I  want  to  go  out  in 
the  automobile."  There  was  retention  of  urine  as  well  as 
frequent  untidiness.  She  was  but  partially  oriented  as  to  her 
surroundings.  The  temperature  was  slightly  elevated,  99°  to 
100°,  and  the  pulse  was  rapid,  82  to  100.  She  was  destructive 
to  clothing  and  resisted  attention.  Some  slight  improvement 
in  recognition  of  her  surroundings  occurred,  but  this  was 
attended  by  increased  irritability.  Control  over  the  lower 
extremities  grew  feebler;  the  gait,  staggering.  Eventually 
a  severe  epileptiform  seizure  occurred.  This  patient  showed 
the  Hutchinson  notched  teeth.  At  the  time  she  was  lost  to 
observation  there  was  spasticity  of  the  lower  extremities  and 
a  tendency  to  contractures. 

In  many  cases  such  as  the  foregoing  contractures 
proceed  to  shocking  deformity. 

Dementia  with  Paralysis. 

This  is  a  form  of  dementia  produced  by,  and  depend- 
ent upon,  previous  damage  to  the  brain,  by  an  apoplec- 
tic attack,  the  occlusion  of  some  blood-vessel  cutting  off 
the  nutrition  of  certain  parts  of  the  brain,  or  cerebral 
degeneration  in  some  of  its  forms.  Here  well-defined 


INSANITY.  131 

delusions  are  rare,  but  there  are  great  irritability,  emo- 
tional disturbance,  perversions  of  feeling,  and  a  tend- 
ency to  misconstrue  the  motives  of  others. 

The  outlook  in  this  disease  is  unfavorable.  Impair- 
ment of  the  bodily  and  mental  health  is  apt  to  go  slowly 
on.  Death  may  occur  from  apoplexy  or  an  epilepti- 
form  or  apoplectiform  seizure. 

Insanity  from  Syphilis. 

Disturbances  of  mental  operations  the  direct  result 
of  functional  or  organic  brain  disease  from  syphilis  are 
encountered.  They  appear  in  connection  with  syphi- 
litic arterial  disease,  with  new  growths,  with  meningeal 
inflammation.  In  the  early  period  of  brain  syphilis 
there  may  appear  a  neurasthenoid  condition,  with  diffi- 
culty differentiable  from  neurasthenia  proper.  Occa- 
sionally confusional  excitement  occurs.  Most  com- 
monly mental  symptoms  of  a  morbid  character  follow 
epileptiform  or  apoplectiform  seizures.  They  are 
those,  as  a  rule,  of  dementia,  with  irritability  and  emo- 
tionality. The.  impairment  in  the  memory  sphere  is 
conspicuous,  and  bewilderment  is  occasionally  of  that 
degree  that  recognition  of  the  surroundings  is  imper- 
fect and  the  patient  encounters  the  danger  of  wander- 
ing away  from  home  and  forgetting  his  name  and 
residence.  The  acts  of  the  morning  are  forgotten  by 
afternoon,  and  the  acquisition  of  names  of  new  ac- 
quaintances is  impossible.  Epileptiform  and  apoplecti- 
form states  attended  by  paresis  or  paralysis  occur. 

Treatment. — These  conditions,  being  the  direct  re- 
sult of  the  syphilitic  bacillus,  are  more  or  less  amenable 
to  methods  employed  for  the  extermination  of  the 


132  INSANITY. 

spirochsetse.      A   very   positive   Wassermann   reaction 
should  determine  vigorous  specific  treatment. 

Manic-Depressive  Insanity. 

Under  this  head  are  included  the  recoverable  psy- 
choses heretofore  designated  as  acute  mania,  subacute 
mania,  simple  melancholia,  melancholia  with  frenzy, 
and  melancholia  with  stupor,  as  well  as  the  mixed 
chronic  form  of  disease  characterized  by  alternating 
periods  of  excitement  and  depression,  the  so-called  re- 
current mania  (folie  circulaire),  or  alternating  insanity. 

In  the  manic  or  excited  phase  of  manic-depressive 
insanity,  the  mental  disturbance  is  of  recent  onset  and 
its' leading  characteristics  are  changing  delusions  and 
active  excitement. 

Its  development  is  usually  somewhat  sudden,  al- 
though it  will  be  found  as  a  general  thing  that  trie 
patient  has  suffered  for  some  time  before  excitement 
occurs  from  depression,  emotional  instability,  sleepless- 
ness, loss  of  appetite,  constipation,  and  other  derange- 
ments of  the  bodily  functions.  When  excitement  ap- 
pears the  patient  becomes  noisy,  restless,  at  first  irrele- 
vant, then  incoherent  in  conversation,  irritable,  and 
impulsive.  All  grades  of  excitement  are  encountered, 
from  extreme  restlessness  to  complete  lack  of  self- 
control.  Excitement  may  proceed  to  that  degree  that 
the  patient  is  never  quiet  when  awake.  There  are  ex- 
travagance in  speech  and  frequently  religious  exalta- 
tion and  conversation  on  Biblical  subjects.  The 
'patient  is  by  turns  patronizing  and  antagonistic.  He 
offers  large  sums  of  money  for  trifling  services,  is 
conscious  of  great  power.  One  wishes  to  be  dressed  in 
white  because  this  color  is  emblematic  of  purity,  would 


INSANITY.  133 

will  her  property  to  the  nurse,  denies  her  parents'  rela- 
tionship to  her,  and  conceives  herself  a  superior  being; 
believes  she  can  save  souls,  that  her  touch  is  magical. 
With  such  extravagant  fancies  there  may  be  fear  of 
fire  and  assault  and  hallucinations  of  the  presence  of 
animals.  One  may  be  obscene  one  moment,  in  prayer- 
ful mood  the  next.  In  the  midst  of  obscene  and  pro- 
fane talk  the  patient  declares  he  is  working  for  the 
Lord.  Delusions  in  respect  to  religious  sects  and  fra- 
ternal orders  are  often  mentioned.  There  is  sexual 
excitement  and  masturbation  is  common.  One  patient 
I  knew  declared  that  a  colored  woman  had  given  him 
cantharides  to  exalt  sexual  desire.  Assaults  are  made. 
The  patient  asks  for  water  only  to  dash  the  glass  to 
the  floor.  He  spits  upon  those  who  come  near  and  is 
often  otherwise  untidy.  He  imagines  himself  charged 
with  electricity  and  can  shock  others  unto  death. 

Psychological  Analysis : — 

Sensation  is  lively,  impressions  travel  quickly,  and 
are  largely  objective  and  pleasurable,  although  these 
may  change  rapidly  to  the  painful. 

Perception  is  false.  Hallucinations  of  sight  and 
hearing  occur ;  they  are  usually  pleasurable  but  are  apt 
to  change  suddenly.  Illusions  may  be  present. 

The  Memory  is  temporarily  impaired;  percepts  are 
registered  in  a  distorted  way  and  inaccurately. 

The  Organic  Memory  is  changed ;  the  personality  is 
changed,  leading  to  delusions  such  as  those  of  great 
strength  and  power,  or  that  of  a  superior  being. 

The  Ideation  is  interrupted.  Percepts  come  into  con- 
sciousness one  after  another  irregularly,  are  not 
grouped  into  concepts  accurately,  are  incoherent,  fleet- 
ing, and  disorderly.  Flight  of  ideas  occurs. 


134  INSANITY. 

The  Reasoning  and  Judgment  are  impaired.  There 
is  incoherence  in  the  grouping  of  concepts.  Delusions 
are  of  a  changing  character  and  usually  pleasurable. 
There  is  frequently  religious  exaltation,  the  impression 
of  divine  command,  of  a  call  to  preach  and  of  in- 
spiration. 

Feeling. — Emotions  exalted  and  pleasurable  for  the 
most  part,  but  changeable  as  the  hallucinations  or  delu- 
sions change. 

Volition. — The  will  is  impaired.  Mental  reflexes  are 
prompt,  but  inhibitory  control  is  lost  or  greatly  im- 
paired. Assaults  are  made  impulsively  and  blows  and 
kicks  are  dealt  to  others  because  of  the  irregular,  ex- 
cited muscular  action  constantly  present.  The  clothing 
and  bedding  are  destroyed ;  the  patient  breaks  windows 
and  damages  furniture.  He  denudes  himself  and  ex- 
poses his  person  shamelessly.  Erotic  excitement  is 
present.  The  attention  is  fixed  with  difficulty,  one 
thing  after  another  engaging  it  temporarily.  Impres- 
sions are  largely  objective,  and,  being  derived  from 
different  objects  in  rapid  succession,  are  fleeting  and 
inaccurate.  There  is  great  pressure  of  activity. 

Physical  Symptoms. — The  circulation  is  rapid,  the 
skin  hot,  the  tongue  dry  and  coated,  eyes  suffused  and 
congested,  the  temperature  elevated,  the  urine  scanty 
and  high  colored,  the  bowels  at  times  loose,  at  others 
costive,  sleep  fitful.  There  is  rarely  complaint  of  head- 
ache or  other  evidence  of  pain.  There  is  refusal  of 
food  due  to  two  causes:  indifference,  from  constant 
activity,  which  prevents  the  patient  helping  himself  or 
forbids  his  receiving  food  at  the  hands  of  another,  or 
repugnance,  because  of  the  disordered  condition  of  the 
secretions. 


INSANITY.  135 

In  the  excited  phase  of  manic-depressive  insanity 
there  is,  as  a  rule,  no  tendency  to  suicide.  The  habits 
may  be  untidy  by  reason  of  indifference  to  bodily  wants 
and  concentration  upon  delusions  and  morbid  concepts. 

Termination. — The  tendency  of  this  disease  is  to- 
ward recovery,  provided  the  physical  health  can  be 
maintained.  The  excitement  gradually  increases,  par- 
ticularly in  those  cases  where  early  and  careful  treat- 
ment is  not  afforded.  Within  four  to  five  weeks  it 
reaches  its  height,  then  shades  off  slowly,  the  condition 
of  sleeplessness  being  gradually  overcome,  food  taken 
in  better  quantity  and  variety,  the  condition  of  the 
alimentary  canal  improved,  and  a  better  state  of  elimi- 
nation by  the  skin  and  kidneys  occurring.  On  the 
subsidence  of  excitement  a  condition  of  depression,  of 
emotional  disturbance  and  weakness  of  will  is  present. 
There  are  at  this  time  lack  of  appreciation  of  the  past 
condition,  restlessness,  fault-finding,  a  feebleness  of  at- 
tention and  of  reasoning  and  judgment.  Later,  if  the 
patient  recovers,  these  morbid  feelings  disappear. 

Treatment. — In  the  treatment  of  this  form  of  excite- 
ment perfect  rest  should  be  given  the  patient  so  far  as 
practicable,  avoiding,  if  possible,  the  use  of  manual 
and  mechanical  restraint.  The  ice-cap  to  the  head,  the 
use  of  strychnine  and  other  cardiac  tonics,  and  reme- 
dies to  promote  elimination  are  of  the  utmost  value. 
A  course  of  calomel  in  small  doses  should  be  given  at 
least  twice  a  week,  the  bowels  being  kept  in  soluble 
condition  meantime  by  the  exhibition  of  salines  and 
other  laxative  drugs,  and  the  use  of  the  colon  flushing. 
In  this  condition  there  is  invariably  an  autotoxic  state  to 
which  medical  therapy  should  be  principally  directed. 
The  diet  should  be  nourishing  and  liberal,  the  patient 


136  INSANITY. 

being  induced  to  take,  at  such  times  as  his  attention 
can  be  gained,  milk,  malted  milk,  eggnog,  soups, 
broths,  cream  toast,  custards,  cornstarch,  and  other 
light  and  quickly  prepared  dishes.  Sedatives  should  be 
avoided  in  the  daytime,  but  a  dose  of  veronal  or  sul- 
fonal,  10  to  15  grains,  followed  three  or  four  hours 
later  by  20  grains  of  chloral,  with  or  without  valeria- 
nate  of  ammonia  or  strychnine,  will  usually  be  suffi- 
cient to  induce  a  quiet  sleep  of  several  hours.  A  small 
amount  of  exercise  in  the  open  air  may  be  permissible, 
provided  excitement  is  not  increased  thereby,  and  pro- 
vided the  patient  can  be  isolated  from  other  people. 
The  patient  is,  however,  better  if  left  much  of  the  time 
quietly  in  his  room  under  the  supervision  of  a  vigilant 
nurse,  who  will  give  attentions  when  they  can  be 
offered  without  contributing  to  excitement  and  will 
forego  or  postpone  them  when  tact  suggests  this  course. 
To  minimize  destructiveness,  bedding  of  a  non-de- 
structible character  should  be  provided.  Where  indis- 
pensably necessary,  to  prevent  rapid  exhaustion  and 
for  the  purpose  of  giving  nursing  attention,  the  rest 
sheet  may  be  employed.  The  prolonged  tepid  bath  of 
several  hours'  duration  is  of  great  calmative  and  cura- 
tive value  in  these  cases. 

During  the  critical  period  of  convalescence  of  which 
mention  has  been  made,  the  patient  should  be  safe- 
guarded from  over-mental  stimulation  and  should  be 
judiciously  cared  for  until  such  time  as  the  bodily 
health  is  fully  restored  and  mental  stability  re-estab- 
lished. 

Depressed  Phase. — The  reverse  of  the  picture  dis- 
played in  the  maniacal  or  excited  phase  of  manic-de- 
pressive insanity  is  found  in  the  melancholic  or  de- 


INSANITY.  137 

pressed  phase.  Here  mental  action  is  slowed,  concepts 
and  delusions  are  of  a  painful  character,  and  vague 
impressions  of  a  distressing  nature  put  a  check  upon 
conduct.  Every  grade  is  encountered  from  simple  de- 
pression, a.  feeling  of  gloom  and  despondency  without 
delusions,  to  deep  depression  with  painful  delusions, 
depression  with  agitation  and  motor  restlessness,  or  a 
condition  of  frenzy. 

One  may  develop  all  of  the  above  symptoms  or  in  its 
manifestations  the  disease  may  be  limited  to  any  one 
to  which  reference  has  been  made.  Furthermore, 
there  may  be  episodal  or  intercurrent  alternations  of 
gloom  with  exaltation,  but  the  dominant  note  is  one 
of  anxiety  and  distress.  The  development  of  the  condi- 
tion is  slow.  Constipation  and  auto-injoxication  figure 
largely  in  the  etiology.  There  is  at  first  a  feeling  of 
heaviness  and  gloom.  There  is  failure  of  attention; 
patients  tire  of  their  tasks  easily  and  overlook  business 
details.  Gradually  the  condition  deepens,  the  patient 
feels  a  sense  of  worthlessness  and  wretchedness,  there 
is  a  disposition  to  shun  other  people  and  to  avoid 
mental  effort  altogether.  The  patient  is  gloomy  and 
dejected,  indifferent  to  exercise,  works  only  under 
prompting  and  does  not  carry  tasks  to  completion.  A 
step  further  ancf  delusions  of  a  painful  character  de- 
velop. In  explanation  of  the  feeling,  the  patient  attrib- 
utes his  distress  to  a  sinful  state  and  perhaps  seeks 
consolation  in  religious  exercises.  These  add  fuel  to 
the  flame  and  delusions  that  the  soul  is  lost,  that  the 
patient  has  committed  the  unpardonable  sin,  and  that 
everything  is  wrong  with  the  spiritual  state,  appear. 
"It  was  with  inward  horror,"  says  one,  "that  I  sank 
into  the  abyss  and  confronted  the  inevitable.  I  knew 


138  INSANITY. 

it  with  a  certainty  and  positiveness  compared  with 
which  the  axioms  of  mathematics  are  the  vaguest 
rumors  and  hearsay." 

In  some  cases  the  going  over  into  a  delusional  state 
is  determined  by  the  injudicious  talk  of  friends,  or  by 
the  babble  of  faith  curists  and  Eddyites.  Character 
may  be  given  to  the  delusions  by  the  ill-considered 
outgivings  of  those  in  whom  the  patient  confides.  One 
in  a  morbid  nervous  state  was  told  by  a  so-called  Chris- 
tian Scientist  that  there  was  no  such  thing  as  death. 
This  she  came  to  believe,  turning  it  over  and  over  in 
her  mind  interminably  until  the  delusion  that  she  could 
not  die  developed  and  suicide  was  attempted  in  order 
that  she  might  make  a  test  of  the  matter.  Another,  a 
refined  young  woman,  having  had  erotic  thoughts  in 
connection  with  a  painting,  was  told  by  her  priest  that 
she  was  possessed  of  the  devil  and  a  delusion  was  at 
once  determined.  Passages  in  the  Bible,  particularly 
those  of  a  dark  and  somber  hue,  are  read  and  pondered. 
One  believes  herself  possessed  by  evil  spirits ;  that  she 
is  unworthy  of  affection  and  should  be  badly  treated ; 
that  she  has  led  a  dual  life;  that  her  influence  upon 
others  is  bad;  that  she  brought  sin  into  the  world. 
The  patient  is  bent  upon  self-chastisement  or  suicide. 
One  throws  herself  under  a  moving  trolley  car,  another 
takes  poison,  another  severs  an  artery.  One  burns  a 
finger  with  the  idea  of  tasting  early  the  torments  of 
hell  later  to  be  suffered  in  their  fullness.  Patients  re- 
fuse food  because  unworthy  to  take  it.  There  are 
painful  sensations  in  the  skin  leading  to  picking  the 
face.  A  mother  in  this  condition  may  kill  her  baby  to 
save  it  from  future  suffering  and  commit  suicide  to 
escape  an  ignominious  death. 


INSANITY.  139 

A  condition  of  extreme  motor  agitation  may  appear. 
The  patient  moves  restlessly  back  and  forth,  wringing 
her  hands,  moaning  and  deploring  her  wretched  state. 
A  step  further  and  a  frenzied  condition  comes  into 
being.  There  is  no  rest  for  the  patient  day  or  night. 
She  imagines  herself  burning  up ;  that  she  is  being  con- 
sumed by  the  fires  of  hell ;  that  poison  is  administered 
in  food;  that  her  life  is  threatened  in  every  conceivable 
way.  The  color,  red,  in  any  fabric  or  decoration  is 
pointed  out  as  symbolic  of  fire.  One  sees  herself  dis- 
emboweled and  buried  alive.  Sleeplessness  is  present ; 
there  is  loss  of  appetite,  or  at  least  indifference  to  food, 
and  in  the  agitated  and  frenzied  phases  refusal  of  food 
because  of  delusions. 

Psychological  Analysis : — 

Sensation  travels  slowly  in  the  simpler  forms,  rap- 
idly in  the  agitated  and  frenzied  forms,  and  is  in  both 
instances  subjective  and  painful. 

Perception  is  false  and  hallucinations  of  hearing  and 
sight  are  present.  Patients  hear  threatening  voices  and 
have  visions  of  torment.  Illusions  may  be  present. 

The  Memory  is  not  much  impaired.  Organic  mem- 
ory is  impaired,  the  personality  may  be  changed. 
Undoubtedly  the  delusion  of  demoniacal  possession  oc- 
casionally present  in  these  cases  is  due  to  disturbed 
visceral  sensation. 

Ideation  is  particularly  slow  in  those  cases  where 
there  is  hebetude  and  abstraction ;  is  rapid  in  agitated 
and  frenzied  cases. 

Reasoning  and  Judgment:  Coherency  unimpaired 
in  the  lighter  phases,  impaired  in  the  frenzied  phase; 
delusions  are  almost  invariably  present;  there  is  a 
belief  in  unworthiness ;  that  the  unpardonable  sin  has 


140  INSANITY. 

been  committed;  that  the  conduct  of  the  patient  has 
brought  harm  upon  others;  that  he  is  responsible  for 
the  sins  of  the  world;  that  his  family  is  coming  to 
want. 

Emotions  are  depressed  and  painful,  being  depressed 
to  such  a  degree  at  times  that  the  patient  believes  him- 
self incapable  of  mental  feeling. 

Volition. — In  the  simpler  forms  every  act  involves 
distinct  effort.  Inhibitory  control  is  unimpaired.  At- 
tention can  be  fixed,  but  the  effort  is  wearying.  Mental 
reflexes  are  slow  (Retardation).  Assaults  upon 
strangers  or  people  not  related  to  the  person  are  rare. 
Homicidal  assaults  are  sometimes  made  upon  children 
or  near  and  dear  relatives  because  of  the  delusion  that 
want  stares  them  in  the  face  and  that  they  would  be 
better  off  dead  than  alive.  There  is  no  tendency  to 
destructiveness.  In  the  agitated  or  frenzied  phases  in- 
hibitory control  is  impaired  or  lost.  There  are  ex- 
treme agitation  and  restlessness,  and  at  times  so  great 
clouding  of  consciousness  that  sudden  impulsive  acts 
are  made  as  if  prompted  by  the  impressions  of 
delirium.  In  manic-depressive  insanity  of  the  de- 
pressed type  there  is  a  strong  tendency  to  suicide. 

Physical  Symptoms. — In  the  dull  and  apathetic  cases 
circulation  is  slow,  the  skin  pale  and  cold,  the  tongue 
moist  and  coated  and  showing  indentations  from  the 
teeth ;  the  pupils  are  large  and  respond  slowly,  the 
sclerotics  pearly  white.  Temperature  normal  or  sub- 
normal; urination  sometimes  profuse  because  of  in- 
tense emotion;  bowels  invariably  costive;  sleep  fitful 
and  troubled  by  painful  dreams ;  headache  at  the  vertex 
or  occiput  almost  constant,  as  a  rule  worse  in  the  early 
morning ;  appetite  poor,  food  is  refused  from  delusions 


INSANITY.  141 

of  unworthiness  to  eat  or  bringing  want  upon  others. 
In  the  agitated  or  frenzied  phases  there  are  disturb- 
ances of  sensation  of  the  skin  leading  to  picking  of  the 
face  and  scalp  to  remove  fancied  insects  or  vermin. 
The  patient  is  destructive  and  disorderly  because  of  the 
existence  of  delusions.  The  tongue  is  dry  and  coated, 
and  the  physical  symptoms  very  much  the  same  as 
those  in  the  maniacal  phase.  The  tendency  to  suicide 
in  frenzied  cases  is  extreme.  Self-mutilation  fre- 
quently occurs,  sometimes  in  an  abortive  attempt  to 
commit  suicide ;  again  from  the  belief  in  the  offending 
member,  that  the  eye  offends  and  should  be  plucked 
out,  or  that  the  presence  of  the  sexual  organs  has  con- 
tributed to^  the  distress  of  the  patient  and  that  they 
should  be  removed. 

Treatment. — Medicinal  treatment  should  be  directed 
to  the  relieving  of  constipation,  the  condition  to  which 
the  autotoxic  state  is  primarily  due;  to  elimination  by 
the  bowels,  skin,  and  kidneys.  The  bowels  should  be 
kept  free  by  the  use,  two  or  three  times  a  week,  of 
calomel  or  calomel  and  podophyllin,  followed  by 
salines  and  colon  flushing.  The  Russian  bath  and  salt 
glow,  followed  by  a  cold  shower  and  vigorous  rubbing, 
are  of  much  service.  Patients  should  be  kept  in  bed  a 
large  part  of  each  day  and  alimentation  forced.  In 
pleasant  weather  a  short  walk  in  the  open  air  is  of 
service.  This  should  be  taken  where  the  patient  does 
not  come  in  contact  with  inquiring  friends  or  objects 
which  excite  anxiety  or  cause  an  increase  in  the  delu- 
sional manifestations.  The  bitter  tonics,  strychnine, 
and  iron  are  of  service  occasionally.  In  the  agitated 
and  frenzied  states  patients  should  be  kept  as  much  as 
possible  in  bed  and  carefully  nursed.  The  refusal  of 


142  INSANITY. 

food  is  often  a  perplexing  complication,  and  tube-feed- 
ing will  be  frequently  required.  Sleep  should  be  se- 
cured by  the  use  of  a  warm  bath  at  bedtime  and  a 
powder  of  sulfonal,  trional,  or  veronal.  Occasionally 
a  hot  drink  at  bedtime,  as  malted  milk,  or  digestible 
cocoa,  will  be  sufficient  to  induce  a  night's  sleep  with- 
out the  aid  of  medicine. 

Alternating  Type. — In  the  alternating  type  of  manic- 
depressive  insanity,  there  are  periods  of  excitement, 
periods  of  depression,  and  at  times  periods  of  com- 
posure and  complete  lucidity.  The  first  attack  fre- 
quently occurs  at  the  pubescent  age,  or  in  the  woman  a 
little  later,  at  the  age  of  20  or  thereabouts.  Hereditary 
predisposition  is  found  in  a  majority  of  cases,  and 
from  early  childhood  there  are  often  evidences  of 
emotional  instability.  It  is  not  surprising,  therefore, 
that  the  first  symptoms  should  often  present  them- 
selves at  the  age  of  pubescence,  during  which  occurs 
the  earliest  and  most  notable  physiological  crisis  which 
the  system  undergoes. 

All  powers  of  the  mind  are  more  or  less  affected. 
The  symptoms  presented  vary  with  the  stage  of  the 
malady  and  the  intensity  of  excitement  or  the  depth 
of  depression.  In  excitement  the  demeanor  of  the 
patient  may  be  similar  to  that  of  acute  mania,  but  ex- 
citement is  rarely  so  intense.  Well-marked  delusions 
and  hallucinations  are  frequently  absent,  and  there 
may  be  so  perfect  .coherency  as  to  deceive  the  inex- 
perienced examiner.  There  is  extravagance  in  expres- 
sion and  a  high  coloring  of  unimportant  or  immaterial 
matters.  Patients  of  this  class  are  fond  of  miscon- 
struing, and  with  the  slightest  basis  make  embarrassing 
accusations  against  others  with  a  view  of  justifying 


INSANITY.  143 

loss  of  temper  or  impulsive  acts.  They  are  frequently 
sly  and  malicious  and  have  an  aptitude  for  sarcasm  and 
invective  and  a  keenness  in  retort  very  serviceable  to 
one  contesting  guardianship  or  commitment,  in  mysti- 
fying juries.  The  conduct  of  patients  during  excite- 
ment is  mischievous,  and  by  the  inexperienced  attrib- 
utable to  moral  perversion.  They  are  exasperating 
and  trying  to  the  last  degree,  and  one  must  keep  con- 
stant guard  upon  his  own  temper  in  dealing  with  them. 
Many  o>f  the  cases  of  so-called  moral  insanity  are 
properly  classified  in  this  group.  The  patient  desires 
everything  in  sight,  spends  money  recklessly,  borrows 
without  provision  for  making  payment,  shows  fickle- 
ness and  change  of  purpose,  is  loquacious  and  incon- 
sistent, does  not  respect  the  rights  of  property.  He 
whistles  and  sings  to  the  annoyance  of  others,  does 
not  carry  work  on  to  completion,  affects  fantastic 
dress,  is  incapable  of  mental  concentration.  He 
fancies  himself  gifted  as  an  author  or  orator,  and  there 
is  no  sense  of  accountability  for  conduct,  notwithstand- 
ing practically  perfect  ability  to  distinguish  between 
right  and  wrong.  In  the  period  of  excitement  the 
patient  misconstrues  motives,  makes  unfounded  accusa- 
tions, sets  patients  up  against  each  other,  and  patients 
against  nurses.  There  is  impairment  of  the  inhibitory 
control.  At  times  excitement  reaches  an  extreme 
degree,  but  this  is  not  the  rule,  and  careful  inquiry  into 
such  cases  will  develop  the  fact  that  periods  of  pro- 
nounced but  not  deep  depression  and  brooding  have 
alternated  with  those  of  elation  and  good  feeling. 

The  increased  capacity  for  cerebral  effort,  the  as- 
sumption of  responsibility  for  the  affairs  of  others,  and 
the  heightened  emotional  tone  shown  in  the  early 


144  .  INSANITY. 

period  of  excitement  are  well  illustrated  by  the  follow- 
ing letters  from  patients : — 

"A  strange  experience  in  the  drawing-room  last  evening  in 
rather    a    wordy,    quite    unintelligible    conversation    with   the 

musical  voiced  Mrs.  .     She  asked  me  if  I  had  ever  been 

in .    No,  but  I  should  have  been,  for  one  of  my  brothers 

studied  four  years  at College.     She  had  been  there  (she 

was  in  some  haste  to  tell  me)  and  knew  Mrs. ,  and  I  said 

my  brother  married  her  eldest  daughter  and  Mrs.  after- 
wards studied  medicine  and  became  Dr. of  .  Then 

she  said  that  she  herself  was  sent  there  for  six  months  chap- 
eroned by  and  under  the  care  of  Dr.  where  she  took 

lessons  on  the  piano,  elocution,  etc.     She  also  told  me  that 

Dr. was  at  that  time  losing  her  memory.     She  spoke  it 

very  delicately  for  that  was  'the  skeleton  in  the  closet'  for 
them  all  until  she  entered  into  Rest  Eternal,  a  dozen  years 
after,  but  they  managed  to  care  for  her  at  the  homes  of  her 
daughters.  Then  there  was  a  rambling,  one-half  incoherent 
talk  about  Unitarianism,  Swedenborgianism,  a  little  Presby- 
terian, and  also,  'piscopalianism.  I  could  not  help  wondering 
if could  not  induce  her  to  stop  whispering  aloud  to  her- 
self just  in  the  dining-room,  for  then  she  would  be  very  pre- 
sentable. It  seems  to  me  she  has  been  'cracked'  by  not  being 
founded  on  the  Rock,  Christ  Jesus,  when  she  was  young  and 
plastic  and  then  later  tried  to  satisfy  her  cravings  with  the 
visionary  philosophy  of  Swedenborg  which  was  not  made  for  a 
shallow,  flattered  society  girl,  and  nothing  better  supplied 
by  a  strong,  kind  teacher.  She  is  quite  interesting  to  me  and 
has  made  me  a  game  of  logomachy  cards  to  take  home  to  my 
bairns.  She  had  been  working  all  the  afternoon  until  her  head 
ached  upon  fitting  down  to  her  unsylph-like  figure  the  new 
waist  they  had  sent  her  from  home.  The  smile  of  'the  chessy 
cat'  whatever  that  critter  may  be,  will  doubtless  die  away 

especially  if  the  glare  of does  its  deadly  work.    Mrs. • 

maid  needs  to  be  asked  to  part  Mrs.  hair  with  more 

nicety,  especially  in  the  back.    Amen." 

Dear  Dr.  Burr:     Please  allow  me  to  take  a  minute  to  tell 
you  that  I  am  fully  aware  that  my  present  condition  is  one  of 


INSANITY.  145 

"elation."  But  I  believe  and  hope  I  shall  go  safely  through 
without  a  "bust-up."  Your  kindness  and  the  consideration 
extended  me  by  all  your  staff  are  highly  appreciated.  I  am 
sleeping  fairly  well  now,  have  good  appetite,  and,  of  course, 
life  has  a  good  deal  of  sunshine  for  me  just  at  present.  As 
you  know,  about  the  only  time  I  can  write,  or  compose,  any- 
thing worth  anybody's  reading  is  during  a  period  of  elation : 
so  I  feel  as  though  I  should  "make  hay  while  the  sun  shines ;" 
but  I  do  not  intend  to  inflict  much  or  many  (?)  of  my  lucu- 
brations upon  yourself. 

Very  respectfully  yours, 


During  the  period  of  depression  the  patient  is  dull 
and  listless.  He  lacks  energy  and  application,  is  in- 
different to  exercise,  inclined  to  remain  in  bed.  His 
conduct  -is ~  similar  to  that  heretofore  discussed  under 
the  depressed  phase,  but  there  is  usually  an  absence 
of  fixed  delusions.  As  excitement  is  less  than  that  of 
the  manic  phase,  so  the  depression  is  less  pronounced 
than  in  the  melancholic.1  In  proportion  to  the  gravity 
of  the  first  will  be  found  as  a  rule  the  intensity  of  the 
second,  the  pendulum  swinging  from  one  extreme  to 
the  other.  In  depression  the  patient  is  frequently  re- 
morseful for  unpleasant  acts  done  during  excitement. 
Depression  may  shade  off  into  complete  composure 
and  lucidity,  of  weeks',  months',  or  years'  duration,  or 
on  its  subsidence  excitement  may  again  make  its  ap- 
pearance, 

Physical  Symptoms. — In  the  period  of  excitement 
all  the  bodily  functions  may  be  carried  on  normally. 
There  is  heightened  good  feeling  and  a  condition  of 
well-being.  In  depression  there  appear  constipation, 


1  There  are  exceptions  to  this.    Now  and  again  excitement 
is  intense  and  depression  extreme. 

10 


146  INSANITY. 

sleeplessness,  headache,  distaste  for  food,  painful  sen- 
sations coming  from  the  internal  organs,  dyspepsia. 
Dysmenorrhcea  is  common,  and  gastralgia  contributes 
to  the  patient's  distress.  There  is  occasionally  tachy- 
cardia in  excitement.  In  depression  the  vascular  tone 
is  low.  There  is  complaint  of  pain  in  the  head,  and 
in  the  morning  subnormal  temperature  may  be  present. 
Treatment. — Efforts  in  the  care  of  cases  of  this  class 
should  be  directed  to  mitigating  excitement  and  direct- 
ing muscular  effort  into  useful  channels  during  the 
elated  period;  to  stimulating  and  uplifting  during  the 
period  of  depression.  As  a  rule,  it  will  be  found  that 
in  proportion  as  this  can  be  accomplished  the  symp- 
toms of  the  succeeding  period  will  be  ameliorated.  If 
excitement  is  extreme  and  of  long  duration  the  suc- 
ceeding depression  will  be  deep  and  the  physical  forces 
impaired  correspondingly.  Exercise,  and  so  far  as 
practicable  work  in  the  open  air,  should  be  prescribed 
for  the  patient  during  elation.  If  the  morbid  energy 
can  be  diverted  into  useful  channels  much  is  gained. 
As  a  rule,  during  elation  little  medicinal  treatment  will 
be  required.  Attention  to  the  diet  may  be  demanded 
in  exceptional  cases  where  excitement  is  extreme  and 
the  patient  uses  up  strength  with  great  rapidity.  The 
prolonged  bath  in  the  excitement  of  certain  exceptional 
cases  is  desirable.  During  the  depressed  period  the 
regime  to  be  followed  is  like  that  employed  in  the  care 
of  those  suffering  from  the  depressive  phase  of  the  dis- 
ease heretofore  mentioned.  The  bowels  should  be  kept 
free  by  laxatives  supplemented  by  high  enemas.  Diet 
should  be  of  a  nutritious  character,  and  the  patient's 
repugnance  to  food  overcome  by  urging.  Inasmuch  as 
there  are  no  delusions  which  impel  to  abstinence  from 


INSANITY.  147 

food,  insistence  on  the  part  of  the  nurse  will,  as  a  rule, 
be  competent  to  overcome  the  patient's  disinclination 
to  eat  and  nutrition  may  be  fairly  maintained.  While 
the  disposition  to  lie  in  bed  may  be  indulged  in  a  meas- 
ure, a  moderate  amount  of  exercise  in  the  open  air 
every  day  should  be  insisted  upon,  and  so  far  as  practi- 
cable the  patient  encouraged  to  engage  in  light  forms 
of  manual  employment. 

The  Presenile  (Involutional)  and  Senile 
Insanities. 

As  a  result  of  the  breaking  down  of  the  nervous 
system  due  to  arteriosclerosis  and  cell  degeneration 
incident  to  old  age,  different  forms  of  mental  perturba- 
tion may  appear.  As  in  one  form  of  manic-depressive 
insanity,  the  early  manifestations  may  be  those  of  ex- 
citement. In  certain  cases  there  are  present  delusional 
states  and  considerable  excitement  and  irritability,  and 
there  is  otherwise  marked  involvement  of  the  emo- 
tional sphere.  The  patient  is  erratic,  impulsive,  and 
boastful.  He  decks  himself  out  in  bizarre  attire,  fills 
his  pocket  with  rubbish  of  all  kinds,  ties  varicolored 
strings  in  his  buttonhole,  is  loquacious  to  garrulity.  He 
is  intolerant  of  suggestion  or  criticism  and,  if  angered, 
does  acts  of  violence.  Cared  for  with  any  lack  of  dis- 
cretion, excitement  is  bound  to  increase  and  may  reach 
a  state  of  frenzy,  terminating  in  exhaustion.  Partial 
recovery  may  succeed  an  attack  of  this  kind  or  it 
may  be  followed  by  the  condition  known  as  senile 
dementia. 

On  the  other  hand,  the  leading  symptoms  may  be 
those  of  depression.  Indeed,  the  term  melancholia  has 
been  restricted  to  the  description  of  that  form  of 


148  INSANITY. 

mental  depression  which  is  incident  to  the  post-climac- 
teric and  presenile  periods  of  life.  The  most  prominent 
features  of  this  condition  are  those  referable  to  the 
bodily  organs.  There  are  visceral  delusions  and  hypo- 
chondriasis.  The  patient  believes  that  no  action  goes 
on  in  the  internal  organs;  that  there  is  closure  of  the 
oesophagus;  that  the  bowels  are  stopped  up,  and  that 
there  is  not  and  can  not  be  any  digestion.  For  this 
reason  food  is  taken  indifferently  and  tube-feeding  is 
at  times  necessary.  The  patient  believes  that  every  act 
of  his  recent  life  has  been  erroneously  done.  If  he  has 
sold  his  farm  he  talks  constantly  about  the  deal,  re- 
gretting it,  and  insisting  upon  repurchase.  Sometimes 
the  insistence  is  so  extreme  that  the  repurchase  is  ef- 
fected at  a  price  in  advance  of  that  of  the  sale.  The 
bargain  consummated,  the  patient  is  overwhelmed  with 
self-reproach,  and  nothing  will  serve  his  purpose  but 
to  dispose  of  the  property  again,  even  at  a  second  sacri- 
fice. All  the  time  he  believes  that  he  and  his  family 
are  destined  for  the  poor-house.  In  the  midst  of  plenty 
he  avers  that  they  are  coming  to  want,  and  is  worried 
day  and  night  over  the  certain  catastrophe  on  just 
ahead.  Certain  patients  hang  their  bad  feelings  upon 
the  most  unimportant  pegs.  One  that  I  knew  attrib- 
uted all  his  troubles  to  the  sale  of  a  boat  in  which  he 
was  interested. 

Visceral  delusions  arising  from  impaired  circulation 
and  deficient  innervation  of  the  internal  organs  give 
birth  to  the  idea  of  dissolution,  and  the  patient  pro- 
claims incessantly  that  the  present  are  his  last  moments 
on  earth.  Pain  may  be  referred  to  the  stomach,  to  the 
organs  of  the  chest,  or  to  the  sexual  organs.  In  one 
instance  a  terrific  orchalgia  was  complained  of,  this 


INSANITY.  149 

notwithstanding  no  external  evidence  of  inflammation, 
congestion,  or  change  in  the  contour  or  consistency  of 
the  contents  of  the  scrotal  sac.  Patients  thus  suffering 
moan  and  lament  and  are  in  distress  continuously  when 
awake.  They  demand  hypnotics  and  secure  sleep 
largely  through  these  medicines.  The  blood-pressure 
in  exceptional  cases  may  be  extremely  high. 

The  third  condition  incident  to  the  senile  state  is 
that  of  dementia.  There  is  impairment  of  all  the 
faculties  of  mind.  There  are  delusions,  lack  of  appre- 
ciation of  surroundings  and  extreme  mental  confusion. 
The  patient  is  unable  to  dress  or  undress  himself 
properly.  Memory  for  recent  events  is  obliterated,  for 
remote  events  imperfect,  and  may  or  may  not  be  an- 
nihilated. Recent  concepts  are  not  registered.  There 
is  meaningless  chattering.  The  patient  putters  about 
and  is  a  source  of  constant  anxiety  to  those  having  his 
care  by  reason  of  the  danger  from  falls  and  other  ac- 
cidents. He  is  apt  to  be  out  of  bed  and  wandering  in 
his  room  at  night  and  needs  constant  attention,  which, 
however,  he  is  apt  to  resist  to  the  limit  of  his  strength. 

Treatment. — The  general  rules  of  treatment  laid 
down  for  the  care  of  cases  of  manic-depressive  insanity 
in  excited  and  depressed  periods  are  adapted  to  the 
similar  states  in  presenile  and  senile  conditions.  The 
bowels  should  be  kept  regular,  attention  should  be  paid 
to  the  diet,  tonics  administered  regularly,  and  hypnotics 
from  time  to  time  as  indicated.  Special  nursing  atten- 
tion is  necessary  for  these  cases  to  keep  them  out  of 
mischief  and  to  prevent  injury  to  themselves  or  others. 
In  some  cases  of  presenile  melancholia  the  contempla- 
tion of  suicide  is  strong  and,  it  may  be  regretfully 
added,  is  occasionally  accomplished. 


150  INSANITY. 

Experience  with  a  case  of  involutional  melancholia 
in  which  blood-pressure  was  200  on  admission  and  for 
three  months  never  fell  below  150,  the  average  being 
about  170,  is  of  great  interest  because  of  the  outcome. 
This  patient  had  been  sentenced  to  death  by  the  home 
neurologist,  the  assumption  existing  of  cerebral  arterio- 
sclerosis of  extreme  degree.  The  relation  between 
blood-pressure  and  the  emotional  states  was  striking 
and  invariable.  With  anxiety  and  restlessness  (she 
was  violent  and  suicidal  and  entertained  divers  delu- 
sions, among  which  was  that  she  had  swallowed  some- 
thing which  occasioned  intestinal  obstruction,  and  that 
she  had  committed  the  unpardonable  sin),  blood-pres- 
sure promptly  mounted.  Once  it  reached  200  because 
of  fretfulness  over  a  change  of  room  and  again  185 
for  an  equally  unimportant  reason.  Lowering  of 
blood-pressure  and  relief  in  the  emotional  sphere  in- 
variably followed  the  cabinet  bath.  Medicines  em- 
ployed were  iodide  of  potassium  and  nitrate  of 
sodium  in  small  doses  three  times  a  day.  Medication 
was  not  uninterrupted,  blood-pressure  readings  fur- 
nishing indication  for  its  withdrawal  and  resumption. 
Incidentally  it  is  worthy  of  mention  that  laceration  of 
the  perineum  was  extreme  and  there  was  complete 
procidentia  uteri.  Operation  was  not  permitted  by  the 
friends,  although  desired  by  the  patient  and  advised  by 
a  competent  gynecologist  and  by  myself.  Recovery 
was  perfect.  Had  there  been  operation  and  rapid  im- 
provement thereafter,  it  is  feared  that  psychiatry 
would  have  been  denied  any  considerable  credit  for  the 
results. 

Patients  suffering  from  senile  dementia  should  be 
carefully  watched  and  waited  upon.  So  far  as  possible 


INSANITY.  151 

they  should  be  freed  from  annoying  attentions,  and 
whatever  means  necessary  to  be  used  in  their  care 
should  be  undertaken  with  extreme  tact  and  gentleness. 
It  is  of  the  greatest  importance  that  the  bowels  should 
be  kept  free.  In  most  senile  cases  strychnine  and  its 
preparations  constitute  the  best  and  most  dependable 
general  tonic.  Beware  of  the  danger  of  falls  which 
often  result  in  fractured  thighs  and  of  ruptured  blad- 
der from  overdistention.  These  complications  are 
much  to  be  dreaded. 

Epileptic  Insanity. 

The  complication  of  insanity  with  epilepsy  is  ob- 
served with  some  degree  of  frequency.  There  is  slow 
deterioration;  and  impairment  of  all  the  mental  facul- 
ties to  complete  annihilation  may  occur.  Along  with 
intellectual  deterioration  there  is  great  emotional  sus- 
ceptibility. Patients  are  irritable,  impulsive,  and 
violent,  and  during  the  excitement  which  arises  from 
time  to  time  in  the  progress  of  the  disease  may  be  ex- 
tremely dangerous.  With  all  the  irritability,  intoler- 
ance, and  disregard  for  others,  there  is  in  the  early 
stage  of  the  disease,  before  mental  degeneration  has 
become  too  far  pronounced,  a  strain  of  religiosity. 
Patients  of  this  class  study  their  Bibles  with  great 
earnestness.  They  are  fond  of  employing  Scriptural 
quotations  and  are  critical  of  even  the  slightest  moral 
lapses  on  the  part  of  others.  In  institutions  epileptic 
patients  seek  the  society  of  each  other  and  may  con- 
spire against  the  nurses. 

During  or  following  the  condition  known  as  status 
epilepticus,  where  repeated  convulsions  occur  in  the 
course  of  a  day  or  several  days,  a  prolonged  period  of 


152  INSANITY. 

confusional  excitement  may  occur.    At  such  times  the 
patient  is  highly  dangerous. 

Treatment. — In  the  care  of  cases  of  epileptic  in- 
sanity, the  bromides  and  tonics  must  be  depended  upon 
as  a  regular  prescription  for  the  allaying  of  nervous 
excitement.  Exercise  in  the  open  air,  safeguarding  the 
patient  from  injury  and  from  accident  due  to  falls  in 
perilous  situations,  should  be  given.  During  status 
epilepticus  and  epileptic  excitement  the  patient  is  best 
cared  for  in  bed,  withdrawn  from  all  exciting  incidents 
and  anything  calculated  to  arouse  a  nervous  reflex  lead- 
ing to  pugnacity  and  damage  to  property.  During  the 
occurrence  of  frequent  seizures,  chloral  hydrate,  given 
in  20-  to  25-  grain  doses,  with  an  equal  amount  of  bro- 
mide of  potassium,  once  in  three  or  four  hours,  as 
necessary,  is  often  of  great  value. 

The  Hysterical  Insanities. 

The  unchecked  impulses  of  the  hysterical  patient 
may  become  to  such  an  extent  habitual  that  a  true  in- 
sanity develops.  The  acts  of  disorder,  noisiness,  and 
destructiveness  so  prominent  in  these  cases  are  due  to 
impairment  of  the  will  and  inhibitory  control.  There 
is  absence  of  delusions  properly  so  called,  although  the 
patient  may  feign  their  existence.  The  leading  features 
of  the  insane  condition  resulting  from  hysteria  may  be 
of  the  maniacal  or  the  melancholic  type.  Patients  are 
extremely  imitative  and  are  apt  to  do  what  they  see 
other  patients  about  them  doing.  Later  on,  with  ex- 
citement, there  are  the  usual  physical  signs  of  hysteria, 
the  pallid  countenance,  flushed  only  during  active 
mental  disturbance,  the  cold,  clammy  hands,  the  re- 
laxed and  perspiring  skin,  the  dilated  pupils,  the  sen- 


INSANITY.  153 

sation  of  a  ball  in  the  throat.  In  the  depressed  form 
patients  are  extremely  emotional;  they  weep  easily, 
they  suffer,  in  fancy  or  actually,  much  mental  distress ; 
they  are  incapable  of  exertion,  they  permit  their  limbs 
to  become  contractured  from  disuse,  they  present 
paralysis  of  motion  and  anaesthesia.  Terrific  attacks  of 
vomiting  and  strange  vasomotor  disturbances  of  the 
skin  may  be  present.  Such  patients  are  without  delu- 
sions aside  from  those  which  strictly  pertain  to  bodily 
sensations  and  movements.  They  are  not,  as  a  rule, 
suicidal,  but  often  threaten  suicide,  and  one  may  under 
strong  impulsion  seize  a  favorable  opportunity  to  de- 
stroy herself.  I  have  known  the  approach  of  a  train 
of  cars -to  furnish  this  opportunity  to  one  who  I  have 
every  reason  to  believe  was  not  seriously  contemplating 
self-destruction.  It  should  be  remembered  further  that 
acts  committed  for  the  purpose  of  exciting  alarm  or 
sympathy  and  not  intentionally  suicidal  may  result 
fatally. 

Hysteria  may  simulate  meningitis,  acute  maniacal 
conditions,  or  epilepsy.  A  case  of  considerable  interest 
from  a  diagnostic  standpoint  is  the  following: — 

The  patient  was  1-6  years  of  age,  single,  a  student,  and  of 
good  heredity.  He  had  been  delicate,  had  had  otitis  media 
when  a  boy,  and  repeated  attacks  since.  Ten  years  before 
coming  under  my  care  he  had  septic  infection  of  the  lymphatic 
system  of  one  arm.  There  was  suppuration  of  the  glands, 
several  of  which  required  to  be  removed.  In  the  preceding 
January,  he  had  a  severe  attack  of  scarlet  fever,  which  was 
followed  by  quinsy.  Convalescence  was  slow,  and  he  failed 
to  regain  strength.  One  day,  when  sitting  at  table,  he  com- 
plained of  feeling  ill,  and,  suddenly  seizing  his  head,  screamed 
with  pain.  The  physician  who  reached  him  a  few  minutes 
later  found  the  head  and  upper  trunk  intensely  congested  and 
the  extremities  cold.  There  was  extreme  photophobia,  and 


154  INSANITY. 

for  two  weeks  he  was  confined  to  a  dark  room,  a  compress 
covering  the  eyes.  He  improved,  but  a  few  weeks  later, 
returning  from  a.  drive,  had  a  similar  attack.  In  this  one 
he  fell  to  the  ground,  and  the  nurse  in  attendance  reported 
to  the  physician  that  she  believed  that  he  had  had  an  epileptic 
seizure.  The  photophobia  returned,  and  reappeared  at  irregu-' 
lar  intervals  after  that  time.  There  were  attacks  simulating 
petit  mal,  the  face  wearing  a  blank  expression  and  momentary 
unconsciousness  apparently  occurring,  but  certain  symptoms 
preceding  attacks  led  to  the  suspicion  of  a  strong  emotional 
element.  During  the  attacks  he  was  restless  and  confused, 
and  moaned,  cried,  and  talked  deliriously.  The  opinion  of 
the  specialist  called  in  consultation  was  that  meningitis  was 
threatened.  Later  there  was  complaint  of  pain  in  the  stomach, 
and  at  times  the  locality  of  the  pain  suggested  appendicitis. 
Following  an  attack  three  weeks  before  admission  to  Oak 
Grove  Hospital  he  had  aphasia,  and  a  paretic  condition  of 
the  entire  muscular  apparatus.  He  was  unable  to  pick  up 
articles  or  to  write.  Cerebration  was  much  delayed,  and  the 
reflexes  were  slow.  There  was  elevation  of  temperature. 
Constipation  was  present.  It  was  feared  at  the  time  he  came 
under  treatment  that  a  dependence  on  morphine  had  been 
established.  He  had  required  a  small  fraction  of  a  grain 
daily,  was  subject  to  emotional  storms  and  attacks  of  pain, 
and  this  agent  seemed  to  be  required  for  his  relief.  None 
was  given  him  at  the  hospital,  however.  After  resting  in 
bed  for  a  time  with  the  ice-cap  to  the.  head  he  grew  quiet, 
and  the  night  after  admission,  but  for  a  hysterical  attack, 
slept  well  without  medicine.  One  night  only  he  was  wakeful 
and  required  a  hypnotic.  A  note  made  two  weeks  after 
admission  states  that  there  have  been  no  unfavorable  symp- 
toms since  the  first  twenty-four  hours,  and  it  is  believed  that 
the  hysterical  outbreak  of  the  first  evening  was  due  to  the 
injudicious  attention  of  a  nurse  who  came  with  him,  and 
whose  stay  was  insisted  upon  by  the  patient's  friends.  The 
case  emphasizes  the  importance  of  change  of  environment  in 
such  cases.  At  home  the  attention  the  patient  received  was 
fussy  and  injudicious,  and  altogether  disproportionate  to  the 
actual  requirements.  The  condition  was  evidently  aggravated 


INSANITY.  155 

also   by   a    degree   of    eroticism   toward   a   woman   nurse   in 
whose  care  he  had  been  placed  for  several  months. 

Much  light  has  been  shed  in  recent  years  on  the 
mechanism  of  hysteria  through  the  researches  of 
Freud  and  those  of  his  school,  who  attribute  the  oc- 
currence of  the  psychical  explosion  which  characterizes 
hysteria  to  suppression  of  some  experience  of  early 
life  occasioning  trauma  (injury)  of  a  sexual  character. 
The  suppressed  recollection  of  something  which  for  the 
moment  made  profound  impression,  the  defense  against 
the  recollection  induced  by  modesty,  humiliation,  self- 
censure,  or  convention  occasion  a  subconscious 
smoldering  which  under  favoring  circumstances  bursts 
into  flame.  The  muscular  agitation,  the  loss  of  self- 
control,  the  bizarre  movements,  the  outcries,  the  con- 
vulsive phenomena,  are  prompted  by  subconscious  im- 
pulses. Even  as  there  is  eruption  of  the  volcano  when 
pressure  within  exceeds  resistance  from  without,  so 
self-control  is  lost  and  erratic  and  erotic  acts  take  place. 
One  may  refer  to  pain  in  the  abdomen,  as  in  a  case 
which  came  under  my  observation,  and  demand  mor- 
phine and  other  sedatives  for  its  correction,  translating 
a  purely  erotic  fancy  developed  from  sexual  indiscre- 
tion into  actual  pain.  Another,  asked  to  communicate 
in  detail  a  visual  hallucination,  spoke  of  a  fish  bearing 
the  head  of  a  man  swimming  toward  a  woman's  sexual 
parts.  The  outgivings  of  the  patient  in  reference  to  this 
symbol  were  those  of  an  unusual  sexual  experience 
which  had  evidently  occasioned  much  self-censure. 
Through  the  revelation  of  that  which  had  fretted  and 
distressed,  the  hysterical  symptoms  were  completely 
relieved  and  recovery  speedily  followed.  In  this  case 
the  bounds  of  ordinary  hysterical  unrestraint  had  been 


156  INSANITY. 

far  exceeded.  There  was  an  acute  delirious  condition 
accompanied  by  visual  hallucinations  and  frenzied  ex- 
citement. Refusal  of  food  had  led  to  emaciation  and 
debility.  Suicidal  impulses  were  present  to  an  extent 
which  necessitated  close  and  constant  supervision. 

States  of  Obsession. — Closely  allied  to  hysterical  or 
hysteroidal  cases  are  those  showing  besetments  or  ob- 
sessions and  dual  personality.  Morbid  obsessions  are 
of  every  kind  and  degree.  They  pertain  to  the  health, 
surroundings,  and  circumstances  of  the  patient.  They 
interfere  with  his  uprisings  and  downsittings,  and  are 
senseless  and  absurd,  but  they  cause  the  lives  of  those 
they  influence  to  be  to  the  last  degree  wretched.  Tor- 
mented by  doubts,  hesitant  in  performing  acts,  with 
possibly  unimpaired  judgment  as  to  the  proper  course 
to  pursue,  such  patients  vainly  battle  against  the  hor- 
rors of  the  bondage  they  feel,  and  are  deserving  ob- 
jects of  commiseration.  To  one  class  of  the  obsessed 
pertain  those  who  are  constantly  exercised  by  the 
necessity  of  inquiring  into  the  whys  and  wherefores  of 
everything  in  life.  The  smallest  matters  are  minutely 
analyzed,  the  most  commonplace  things  are  subjected 
to  rigid  inquiry,  and  the  patient  is  in  more  or  less  fre- 
quent anguish  because  unable  to  come  to  a  satisfactory 
decision  upon  the  subject  presented  to  his  mind.  This 
may  be  an  extreme  exaggeration  of  a  disposition  dis- 
played by  certain  neurotic  children  to  catechize  upon 
commonplace  matters  to  the  limit  of  their  elders'  en- 
durance. Others  are  deeply  concerned  over  religious 
matters.  They  fear  that  some  essential  religious  ob- 
servance has  not  been  met  and  that,  in  consequence,  a 
sinful  state  has  developed.  Others,  still,  are  beset  with 
fear  and  feel  baseless  and  unreasoning  alarm  from  the 


INSANITY.  157 

elements,  objects,  places,  and  diseases.  One  whom  I 
knew  thought  that  blood  flowing  from  a  cut  finger 
would  harm  those  who  came  near  and  believed  that 
whoever  was  in  the  direction  toward  which  her  hand 
pointed  when  putting  on  her  sleeve  would  be  harmed. 
One  patient  is  compelled  to  count  the  squares  in  the 
pavement  and  the  trees  by  the  side  of  the  walks; 
another  gives  utterance  to  oaths  and  vile  language. 
One  whom  I  knew  betrayed  no  other  evidence  of  dis- 
ease, aside  from  general  reduction  in  mental  strength, 
but  was  beset  by  an  impulse  to  kill  his  wife  and  had 
sharpened  a  knife  for  that  purpose.  Another  patient 
under  my  observation,  with  perfect  realization  of  his 
condition,  had  impulses  to  strike  and  dreaded  the  time 
when  he  could  no  longer  resist  them.  One  form  of  be- 
setment  is  the  aboulic.  There  is  absence  of  will.  A 
patient  under  my  observation  suffering  from  aboulia 
described  her  condition  as  follows  : — 

'The  first  great  trouble  of  my  life  occurred  about  nine  years 
ago,  when  I  lost  by  death  a  beloved  child.  Two  years  later,  a 
little  son  was  born  to  me.  I  was  far  from  strong  then,  and  it 
was  during  this  pregnancy  that  I  had  my  first  sinking  sp"ell; 
it  was  of  course  attributed  to  my  condition  at  the  time,  but 
they  have  occurred  with  more  or  less  frequency  ever  since. 
Latterly,  there  has  been  a  longer  lapse  of  time  between  the 
spells,  and  not  so  severe.  When  my  baby  was  one  year  old, 
death  deprived  me  of  both  father  and  mother  in  the  course 
of  six  weeks,  and  this,  added  to  many  family  troubles  arising 
at  that  time,  I  think  is  the  direct  cause  of  my  illness,  although 
I  do  not  think  my  disease  reached  its  climax  until  four 
years  ago,  when  I  had  a  miscarriage.  Since  that  time  it  has 
been  impossible  for  me  to  recover  the  mastery  of  my  nerves 
and  self.  My  condition  at  present,  I  think,  is  more  hopeful 
than  morbid,  although  I  have  hours  of  exaltation  and  very 
many  of  depression  when  I  feel  that  I  will  never  get  well; 
in  fact,  only  become  worse  as  the  years  roll  by.  My  un- 


158  INSANITY. 

happiness  consists  more  in  the  fact  that  I  am  unable  to 
contribute  to  my  family's  happiness  than  on  my  own  account, 
for  I  think  I  could  easily  accommodate  myself  to  circum- 
stances. 

"My  nervousness  takes  several  forms.  In  an  undefined 
dread  which  makes  me  feel  unsafe  when  abroad,  when  at 
the  homes  of  my  friends  or  shopping,  which  when  persisted 
in  by  me  as  a  means  of  cure,  causes  untold  mental  suffering, 
introspective  reasoning,  faintness,  general  restlessness,  and 
intense  pain  of.  all  the  nerves  covering  the  entire  body,  but 
severest  in  the  hands  and  knees.  This  condition  is  the  same 
while  entertaining  in  my  own  home,  not  usually  so  severe,  but 
is  present  more  or  less  all  the  time,  although  at  home  I  am 
more  able  to  control  myself  on  account  of  the  feeling  that 
when  my  powers  of  endurance  give  out,  I  can  retire  to  the 
privacy  of  my  own  apartments  and  send  for  a  physician  when 
necessary.  I  do  not  mean,  to  state  the  following  in  praise  of 
myself,  yet,  I  have  been  able  to  fight  these  unusually  well. 
I  merely  state  this  fact,  for  I  have  often  been  told  it  was 
only  imagination  on  my  part  and  that  if  I  would  only  exercise 
a  stronger  will-power,  I  could  do  much  to  help  myself.  These 
pains  in  my  knees,  which  I  spoke  of  before,  are  very  severe 
at  times,  and  always  accompany  or  follow  a  restless  night  or 
worry  of  any  kind.  The  other  forms  of  nervousness  are  a 
longing  to  cry  at  tinfes,  weakness  of  limbs,  and  trembling. 

"I  have  no  physical  weakness  to  complain  of.  For  a  time, 
I  supposed  my  heart  weak,  and  thought  each  sinking  spell 
meant  death.  I  overcame  that  fear,  and  am  only  rarely 
troubled  with  palpitation.  Appetite  good,  sleep  fairly  well, 
and  am  quite  accustomed  to  being  told  I  look  well,  yet  I  feel 
far  from  strong,  and  am  tired  to  exhaustion  most  of  the 
time.  I  often  wish  I  had  absolutely  nothing  to  do,  no 
responsibilities ;  and  yet,  I  have  found  that  by  keeping  myself 
very  busy,  I  can  ward  off  a  nervous  attack." 

The  obsession  may  be,  as  in  one  case  under  my  care, 
of  the  swallowing  or  having  swallowed  some  deleteri- 
ous substance  as  pins  or  needles,  or  that  in  some  way 
or  other  all  lost  pins  and  needles  made  their  way  into 


INSANITY.  159 

her  stomach.  Obsession  of  words  has  been  discussed 
at  length  in  the  section  on  "Symbolism  in  Sanity  and 
in  Insanity." 

Other  forms  of  obsession  are  closely  related  to 
manic-depressive  states  and  to  dementia  praecox.  The 
leading  feature  of  these  cases  is  horrible  and  persistent 
fear.  In  one  case  it  was  that  of  pursuit  by  electricians, 
compulsory  marriage,  and  conspiracy  in  which  her 
brother  was  involved.  There  was  also  fear  of  conta- 
gion and  of  sexual  assault.  She  heard  disparaging 
remarks  as  coming  from  distant  voices  which  accused 
her  of  having  a  bad  disorder,  had  an  impression  of 
being  infected  from  a  stool  in  the  water  closet,  and 
thought  to  prevent  sexual  assault  by  wearing  a  rubber 
bag  over  the  pelvic  region.  She  believed  herself  re- 
sponsible for  trouble  about  to  come  upon  her  family. 

A  young  woman,  a  bright  student  in  school,  of  a  highly 
religious  turn  of  mind,  was  advised  by  an  Evangelist  that  a 
young  man  who  was  interested  in  her  was  not  a  Christian  and 
that  if  she  married  him  she  would  have  a  soul  on  her  hands. 
She  sustained  several  attacks  of  hysteria,  one  incident  to 
attendance  upon  revival  meeting.  There  were  disturbance  of 
attention,  confusion,  and  self-depreciation.  She  received  sug- 
gestions from  different  articles  of  food.  "If  I  eat  that 
onion,"  she  said,  "and  know  that  several  other  people  eat 
them  at  the  same  time,  they  would  all  have  the  same  train 
of  thought  and  all  would  know  that  I  was  menstruating." 
Cocoa  and  chocolate  suggested  negroes;  poached  eggs1  on 
toast,  the  minister  who  had  conducted  the  revival  services. 
Certain  experiences  which  she  did  not  mention  indicated 
strong  sexual  temptation  and  delusions  growing  out  of  them 
were  that  her  spiritual  nature  had  been  destroyed.  Improve- 
ment in  this  case  grew  out  of  confiding  in  the  nurse  and  to 
some  extent  in  myself  and  the  suggestions  to  treat  as  common- 


1  See  section  on  "Symbolism  in  Sanity  and  in  Insanity." 


160  INSANITY. 

places  the  matters  which  had  weighed  so  heavily  upon  her 
mind. 

Dual  Personality. — Dual  personality  is  at  times  en- 
countered as  in  the  following  cases : — 

For  two  years  before  the  patient  came  under  my  observa- 
tion she  was  said  to  have  had  no  recollection  of  incidents, 
although  able  to  carry  on  her  work  and  participate  in  the 
affairs  of  the  household.  During  the  first  attack,  two  years 
before,  she  came  to  the  table  clad  negligently,  was  dull  and 
confused,  appeared  drowsy,  and  in  the  evening  stuporous. 
The  same  night  she  became  delirious  and  appeared  to  be 
resisting  and  fighting  her  mother  (from  whom  she  had  been 
separated).  She  opposed  attention  and  refused  medicine.  She 
assumed  grotesque  positions,  such  as  hanging  over  the  foot- 
board of  the  bed  with  lower  extremities  on  the  bed  and 
arms  on  the  floor,  or  hips  on  the  bed  rail  and  shoulders  and 
back  on  the  floor.  There  were  also  opisthotonos  and  cata- 
leptoid  states.  At  the  end  of  ten  weeks  she  was  much  im- 
proved, but  her  manner  became  entirely  changed.  From  being 
amiable  she  grew  wilful  and  acted  in  opposition  to  the  wishes 
of  her  friends.  There  were  attacks  of  grave  hysteria  for 
months  afterward,  when  suddenly  a  change  occurred.  She 
felt  something  snap  in  the  left  side  of  the  head  and  ap- 
peared as  if  waking  from  sleep,  inquired  how  she  came  to  be 
upstairs,  and  remembered  going  to  sleep  on  the  couch  in 
the  sitting-room,  an  event  which  occurred  eight  months  before. 
There  appeared  to  be  obliteration  of  recollection  of  events 
during  this  time.  A  kodak  which  she  had  learned  to  use 
very  skilfully  was  entirely  unknown  to  her,  and  she  ap- 
peared to  be  unable  even  to  open  the  case,  which  was  operated 
by  means  of  a  concealed  button.  Persons  with  whom  she  had 
become  acquainted  during  the  period  were  as  perfect  strangers. 
It  was  impossible  to  convince  her  that  it  was  summer  season 
until  she  was  taken  to  the  window  and  shown  that  there  was 
no  snow  on  the  ground.  Occasional  hysterical  attacks  oc- 
curred subsequently.  During  the  attacks  she  struck  her  head 
against  the  wall  and  it  was  often  necessary  to  use  force  in 
controlling  her.  She  tried  to  bite  and  would  repeat  petu- 


INSANITY.  161 

lantly,  "I  will  kill  myself."  Later  her  conduct  became  girlish 
and  romping.  She  took  childish  delight  in  riding  her  bicycle 
at  high  speed.  There  was  at  no  time  any  evidence  of 
paralysis. 

Another  patient  took  the  midday  meal  on  Sunday  with  a 
relative.  She  appeared  well.  Three  hours  later  she  was  in  a 
state  of  mental  confusion  which  seemed  to  develop  at  a  reli- 
gious meeting.  The  next  day  she  was  found  on  the  street 
bewildered  and  lost.  She  thought  she  was  in  Pittsburgh. 
Recollection  of  Detroit  and  of  previous  acquaintances  and  in- 
cidents had  been  obliterated.  She  was  quiet,  dull,  and  con- 
fused. She  made  new  associations  and  relearned  the  names 
of  friends.  She  wept  easily,  assigning  as  a  reason  that  she 
could  not  think.  She  received  telegrams,  one  saying  that  her 
father  was  ill  and  asking  an  appointment  with  her  in  Canada. 
Her  friends  had  no  knowledge  of  any  person  of  the  name 
signed  to  the  telegrams,  and  it  was  conjectured,  rightly,  as 
subsequently  developed,  that  she  sent  them  to  herself. 

Fugues. — Cases  like  the  foregoing  in  which  there  is 
sudden  flight  or  confusional  wandering  with  complete 
failure  of  orientation  as  to  time  and  place,  the  so-called 
fugues,  are  of  very  great  interest.  Appearing  in  the 
youthful  subject,  they  are,  in  the  opinion  of  Jung,  the 
substitute  for  a  sexual  impulsion.  That  they  are  in- 
variably due  to  some  suppressed  emotional  strain  is 
altogether  probable,  but  this  need  not  be  of  sexual 
quality)  as  the  following  case  illustrates : — 

A  young  man  28  years  of  age  who  had  sustained  injury  to 
the  eyeball  fifteen  years  before  (an  injury  which  subse- 
quently necessitated  enucleation),  of  hereditary  tendency  to 
mental  disease,  of  good  habits,  industrious  and  serious- 
minded,  suddenly  left  his  business  and  disappeared  as  com- 
pletely as  though  lost  in  midocean.  Ten  days  later,  he  was 
found  by  a  native  boy  on  the  bank  of  a  creek  in  the 
interior  of  Cuba.  He  was  lying  on  his  back,  his  face  blistered 
by  the  broiling  sun.  Much  longer  exposure  must  inevitably 
have  resulted  in  death.  The  native  boy  roused  him  and  gave 

11 


162  INSANITY. 

him  directions  as  to  how  to  proceed.  He  walked  during 
the  balance  of  that  day  and  the  following  night  without 
food,  finally  reaching  a  park  in  Havana.  There  he  was 
identified  by  a  passerby  as  a  fellow-American  and  taken  to 
the  Consulate,  where  provision  was  made  for  his  immediate 
necessities.  Not  then  or  at  any  time  afterward  had  he  the 
slightest  recollection  of  the  incidents  of  travel. 

In  this  case  the  so-called  "complex"  (the  deep,  sub- 
conscious, subtle  association  which  determined  flight) 
did  not  appear  until  three  years  later,  when  in  conse- 
quence of  business  irregularities  skilfully  concealed  for 
a  long  period  he  again  fled  to  avoid  exposure. 

Anxiety  Neuroses. — Related  to  the  hysteric  and 
neurasthenic  states  are  the  anxiety  neuroses.  The 
leading  characteristic  of  these  cases  is,  as  the  name  in- 
dicates, extreme  ap{5rehensiveness.  Delusions  properly 
so  called  are  non-existent.  The  patient  is,  however, 
in  more  or  less  constant  fear  of  loss  of  self-control 
and  of  death.  Dread  of  doing,  anxiety  over  the  pos- 
sible result  of  effort,  concentration  upon  the  sexual 
apparatus,  fear  of  impotency,  pallor,  flushings,  sudden 
perspiring,  distress  in  the  region  of  the  solar  plexus, 
are  accompaniments  of  this  disorder.  It  has  been  at- 
tributed (erroneously,  no  doubt,  in  many  cases)  to  cer- 
tain departures  from  the  normal  in  the  sexual  life.  In 
the  following  case  after  years  of  acute  suffering  the 
patient  was  relieved  by  abdominal  surgery.  His  own 
account  of  the  condition  and  the  results  of  surgical 
care  are  most  interesting: — 

"It  will  perhaps  be  of  some  interest  to  you  to  receive  a 
few  lines  from  me  on  the  subject  of  my  experience  since 

my  return  here,  though  both   Dr.  and   Dr.   have 

probably  fully  advised  you  as  to  the  technical  features  of 
the  operation  performed  "on  me  and  of  its  happy  and  truly 
astonishing  results. 


INSANITY/  163 

"Soon  after  my  arrival  here,  Dr.  suggested  a  farther 

X-ray  examination.  This  was  made  and  disclosed  a  marked 

drop  of  the  stomach,  a  condition  which  Dr.  seemed  to 

regard  as  among  the  principal  disturbing  factors  in  my  case. 

Dr.  however  desired  a  more  or  better  defined  outline 

of  the  lower  bowel  and  accordingly  still  another  X-ray 
examination  was  made  on  the  day  preceding  the  operation. 
This  revealed  a  very  much  mixed  up  condition  of  the  sigmoid 
section  of  the  colon,  the  particulars  as  to  which  you  have 

probably,  obtained  from  Dr.  .  The  existence  of  an 

excess  of  about  18  inches  in  the  colon  at  that  point,  and 
said  to  be  congenital  in  its  origin,  presented  a  rather  pecul- 
iar and  perhaps  exceptional  condition. 

"It  was  a  case  of  worrying  about  a  surplus  rather  than 
a  deficit.  In  the  course  of  the  operation  it  was  discovered 
that  the  appendix  didn't  look  any  too  good  and  its  removal 
has  disposed  of  any  possible  cause  for  alarm  in  that  direction. 
All  these  features,  taken  together  with  the  kink  in  the 
transverse  section  of  the  colon,  as  revealed  by  the  X-ray 

examination  made  in  ,  presented  a  rather  large  area  for 

the  surgeon's  work  and  necessitated  a  long  horizontal  in- 
cision across  the  lower  part  of  the  abdomen  as  well  as  a 
diagonal  one  from  the  region  of  the  stomach  to  the  lower 
right  bowel.  It  is  perhaps  due  in  part  to  the  character  of 
the  incisions  that  I  was  left  quite  sore  and  highly  sensitive 
to  the  slightest  movement  for  quite  a  time  after  the  opera- 
tion. Indeed  the  first  four  or  five  days  I  was  very  sick  and 
generally  miserable*  so  much  so  that  I  don't  think  I  shall 
ever  resort  to  ether  in  search  of  a  soothing  influence. 

"All  the  pain  and  discomfort,  however,  resulting  from 
necessary  surgical  injury  were  very  soon  and  almost  en- 
tirely lost  in  the  otherwise  happy  results  of  the  operation. 
In  so  far  as  the  former  symptoms  of  great  distress,  fear, 
anxiety,  and  morbid  speculation,  etc.,  etc.,  are  concerned,  they 
have  practically  gone.  I  need  not  rehearse  the  past  symp- 
toms, which  represented  to  me  the  full  measure  of  human 
wretchedness  and  which  totalled  a  feeling  of  absolute  hope- 
lessness, in  order  to  emphasize  the  feeling  of  composure 
and  restfulness  and  even  cheer  which  has  come  to  me,  to  all 


164  INSANITY. 

of  which  I  was  a  stranger  for  so  long  a  time.  True,  I  am 
not  as  yet  doing  any  athletic  stunts,  being  still  very  weak  and 
much  reduced  in  weight.  I  am  gaining,  however,  in  that 
respect,  though  very  slowly,  from  day  to  day.  Though  un- 
prepared as  yet  to  resume  my  accustomed  duties,  I  am  pre- 
paring to  leave  for  my  home  today,  where  I  shall  spend 
some  time  in  storing  up  further  strength  and  in  putting  a 
little  flesh  on  a  normally  lean  and  lank  figure — but  I  leave 
here  in  the  realization  that  the  controlling  cause  of  my  past 
troubles  has  been  removed  and  that  I  may  expect  to  be 
back  on  my  job  before  very  long.  My  appetite  is  good — even 
keen  at  times.  My  stomach  is  acting  very  well  and  the  colon 
seems  to.  realize  what  is  expected  of  it,  as  I  am  taking  no 
laxative  only  what  is  called  vaseline  oil  prescribed  by  Dr. 

to   promote   the   desired   action.     In  fine,   unless   I   am 

very  much  deceived,  I  shall  forget  a  harrowing  past  in 
dwelling  on  the  old  German  phrase  'Ende  gut— alles  gut.' " 

Treatment. — In  the  treatment  of  these  conditions  the 
most  important  desideratum  is  the  withdrawal  of  the 
patient  from  the  surroundings  and  circumstances  under 
which  emotional  control  is  with  most  difficulty  exer- 
cised. Hysterical  and  obsessed  patients  are  best  cared 
for  away  from  home  in  a  sanitarium  or  hospital,  where 
the  daily  life  can  be  in  every  respect  regulated.  A 
nutritious  diet,  and  the  modified  rest  cure,  massage, 
hydrotherapy,  and  a  tonic  regime  are  necessary.  The 
bodily  health  should  be  built  up  and  little  by  little  the 
emotional  control  re-established,  by  work  suited  to  the 
individual's  capacity  and  strength,  and  by  gentle  sug- 
gestion and  encouragement.  In  this  work  of  restora- 
tion of  nervous  and  emotional  tone,  months  or  years 
may  be  necessary. 

The  uncovering  of  the  complex  where  this  is  prac- 
ticable with  the  so-called  mental  catharsis  (unburden- 
ing the  patient's  mind  and  bringing  subtle  emotions 


INSANITY.  165 

into  the  open)  through  the  methods  of  psycho-analysis 
is,  as  already  indicated,  of  the  utmost  value  in  selected 
cases.  The  happy  results  of  surgery  in  the  above  case 
emphasize  the  desirability  of  X-ray  examination  and 
the  relief  of  visceroptoses  when  this  is  practicable. 

Idiocy  and  Imbecility. 

These  are  mental1  defects  from  congenital  causes  or 
arrest  of  development  in  infancy.  In  Idiocy  there  is 
complete  absence  of  mental  action,  the  operations  of 
life  being  purely  vegetative. 

Imbecility  is  of  all  grades:  from  that  which  is  ex- 
treme up  through  the  so-called  defective  types  to 
paranoia,  the  highest  form  of  congenital  mental  in- 
firmity. Imbeciles  are  lacking  in  self-control,  are 
irritable,  impulsive,  mischievous,  and  imitative  of  im- 
proprieties. The  higher  faculties  of  the  mind  are 
feebly  developed.  Powers  of  thinking  are  circum- 
scribed. The  emotions  of  imbeciles  are  easily  aroused, 
and  inhibitory  control  is  feeble;  consequently,  they 
often  do  acts  of  violence.  They  are  not,  as  Imbeciles, 
proper  subjects  for  treatment  in  institutions  for  the 
care  of  the  insane — measures  adapted  to  them  being 
more  of  an  educational  than  medical  nature.  Im- 
beciles, like  sane  people,  however,  may  become  insane. 

Paranoia. 

Paranoia  is  a  form  of  disease  occurring  in  one 
of  congenially  defective  nervous  organization,  and 
marked  by  certain  well-defined  symptoms  which  seem 
to  be  due  to  defects  of  development,  and  frequently 
appear  as  an  exaggeration  of  natural  characteristics. 


166  INSANITY. 

One  suffering  from  Paranoia  is  from  childhood 
somewhat  peculiar.  He  may  be  bright  and  receptive  in 
certain  ways,  may  learn  readily  in  school,  but  shows 
eccentricities  of  conduct;  is  self -conceited,  introspec- 
tive, and  develops  unsymmetrically.  Without  obvious 
exciting  cause,  or  with  some  slight  cause,  as  a  fever,  a 
trifling  injury,  or  a  disappointment,  he  becomes  suspi- 
cious. This  feeling  is  usually  at  first  vague  and  indefi- 
nite. Mental  depression  may  proceed  to  a  considerable 
degree.  There  are  associated  with  it,  however,  no  fixed 
delusions  of  unworthiness,  or  of  poison,  as  in  the 
depressed  phase  of  .manic-depressive  insanity,  but 
vague  ideas  of  conspiracy  and  disposition  on  the  part 
of  others  to  deprive  him  of  his  property  or  business 
rights.  A  business  failure,  perhaps,  which  has  been 
the  natural  outcome  of  loose  methods  and  indifferent 
application,  is  charged  up  to  the  machinations  of  those 
inimical  to  him.1 

This  is  the  so-called  "persecutory  stage."  Following 
this  is  what  is  known  as  the  "transition  stage."  Some 
event  may  occur  in  the  patient's  life — a  visual  halluci- 
nation, a  vivid  emotional  experience,  a  dream,  a  fortui- 
tous circumstance,  a  casual  remark  by  another,  or  the 
encounter  of  a  passage  in  reading — which  may  furnish 
to  the  patient  a  key  or  clue  to  the  mysteries  surround- 
ing his  past  career.  He  begins  then  to  see  that  things 


1 1  once  knew  a  patient  who,  in  this  condition,  enlisted  in 
the  army.  He  felt  himself  watched  and  checked  in  his  laud- 
able undertakings  on  every  hand ;  he  believed  that  the  generals 
of  the  army — Sherman  and  Grant — were  conspiring  to  keep 
him  in  the  position  of  private,  and  prevent  his  meeting  that 
reward  in  promotion  to  which  his  abilities  and  meritorious 
conduct  entitled  him. 


INSANITY.  167 

have  thus  been  planned  out  for  him  from  the  begin- 
ning; that  he  was  to  be  brought  up  by  those  claiming 
his  parentage,  to  conceal  his  noble  birth;  that  he  is  a 
prophet,  or  even  Christ.  He  diligently  cons  the  Scrip- 
tures for  references  to  himself,  and  finds  in  this  pass- 
age and  that  the  prediction  of  his  coming;  of  the 
persecution  to  which  he  will  be  subjected;  of  his  ulti- 
mate triumph.  He  sees  now  the  reason  why  he  has 
been  persecuted  in  the  past.  It  has  been  because  of  the 
envy  of  others,  or  because  those  who  knew  of  his 
mental  gifts  or  his  true  social  position  desired  to  keep 
him  from  coming  into  his  inheritance.  One  patient 
conceived  the  idea  that  a  large  branch  factory  in  which 
he  was- employed  as  foreman  built  for  the  purpose  of 
producing  a  line  of  inexpensive  vehicles  was  con- 
structed and  organized  for  the  sole  purpose  of  his 
humiliation. 

Another  believed  that  the  institution  with  which  she 
was  connected  parodied  her  life.  The  logical  sequence 
of  this  delusion  was  difficult  to  obtain,  but  the  idea 
seemed  to  be  that,  because  celibacy  was  enforced 
therein,  she,  being  unmarried,  was  naturally  adjusted 
to  the  condition.  A  patient  admitted  to  the  clinic  in 
Munich  four  years  ago  brought  with  him  massive 
volumes  in  manuscript  decorated  with  hieroglyphics 
and  symbols  indicating  divine  inspiration.  He  was  the 
spiritual  head  of  a  small  religious  sect,  similar,  I  dare 
say,  to  those  founded  by  the  notorious  Schlatter  and 
other  self-appointed  ministers  of  the  Lord.  A  very 
common  delusion  is  that  of  proprietorship  in  an  in- 
stitution in  which  the  lot  of  the  patient  may  fall.  He 
accepts  confinement  and  restriction  as  a  part  of  the 
magnificent  scheme  of  his  life,  and  adjusts  himself  to 


168  INSANITY. 

the  hospital  routine,  the  environmental  horizon  being 
just  sufficiently  near  and  small  to  give  outlet  to  energies 
and  avert  the  confusion,  friction,  and  irritability  inci- 
dent to  contact  with  more  active  minds. 

It  is  not  difficult  to  see  in  the  foregoing  a  description 
of  the  cranks  of  the  world — the  "harmless  insane,"  the 
physician's  office-bore,  and  the  neighborhood  nuisance. 
The  usual  quiet  conduct,  the  continued  application  to 
business,  the  ability  to  converse  rationally  on  current 
topics,  the  bright  memory,  the  logical  method  of  pre- 
senting beliefs,  the  habitual  volitional  control,  fre- 
quently deceive  as  to  the  true  nature  of  the  patient. 

As  a  matter  of  fact,  the  so-called  cranks,  of  this  de- 
scription, constitute  a  dangerous  element  in  society. 
They  are  apt  to  make  sudden  homicidal  assaults  in  con- 
sequence of  delusions.1  Many  of  the  assassins  of  dis- 
tinguished persons  have  belonged  to  the  paranoiac 
class. 

Dementia  is  non-existent  in  these  cases.  Some  retain 
until  late  in  the  disease  tolerably  full  possession  of 
their  original  power  to  think  correctly,  except  in  the 
line  of  their  delusions ;  to  reason  upon  subjects  foreign 
to  themselves;  to  recollect  perfectly;  to  acquire  new 

1  They  believe  that  in  committing  acts  of  homicide  they 
are  benefactors  of  society.  Thus:  CHICAGO,  December  8. — 
Prendergast,  the  assassin,  made  a  formal  protest  against  the 
plea  of  insanity  being  introduced  in  his  case  today.  When 
he  was  led  into  Judge  Brentano's  court  room,  he  handed  his 
attorney,  Mr.  Essex,  a  letter  in  which  he  asked  that  the  in- 
sanity plea  be  withdrawn,  declaring  that  he  believed  people 
will  get  an  idea  that  he  did  not  kill  Carter  Harrison  for  the 
benefit  of  the  people  at  large,  but  rather  from  a  personal  or 
selfish  motive.  Attorney  Essex  declined  to  state  whether  he 
would  give  the  letter  any  consideration. — Press  Report. 


INSANITY.  169 

facts,  and  even  to  display  ability  in  the  line  of  con- 
struction or  invention.  The  foreman  of  the  vehicle 
plant  to  whom  allusion  has  been  made  was  a  most 
accomplished  and  efficient  workman. 

Mr.  F.,  a  paranoiac,  who  was  committed  to  a  South- 
ern hospital  on  account  of  persistent  efforts  to  marry 
a  certain  young  lady,  was  very  much  disturbed  on  ac- 
count of  his  confinement,  and  not  being  able  to  see  his 
lady  love. 

The  superintendent  and  a  friend  of  Mr.  F.,  in  trying 
to  console  him,  suggested  that  "there  were  others." 
The  superintendent  said:  "F.,  there  are  too  many 
women  in  the  world  to  go  daft  over  one  and  you  should 
follow  my  example.  When  I  was  courting,  if  one 
would  not  have  me,  I  simply  dropped  her  and  tried 
another,  until  finally  rinding  one  who  would  have  me." 
The  friend  of  F.  Said,  "Yes,  that  is  right ;  that  is  the 
way  I  did." 

F.  very  coolly  remarked:  "That  might  be  all  right 
for  you  two,  but  I  am  a  little  particular  about  whom  I 
court." 

Cases  of  paranoia  will  frequently  offer  much  diffi- 
culty in  diagnosis.  Owing  to  their  litigious  propensities 
and  the  disposition  to  make  sudden  assaults  in  obe- 
dience to  delusions,  paranoiac  patients  are  especially 
prone  to  get  into  court.  The  examiner  will  find  him- 
self under  the  necessity  of  analyzing  symptoms  care- 
fully and  formulating  a  conclusion  which  clever  and 
close  interrogation  will  not  disturb.  In  paranoia  one 
has  to  deal  with  the  evolution  of  the  crooked  stick. 
Such  patients  grow  up  to  be  insane.  They  are  more 
or  less  erratic  from  childhood,  and  the  point  where 
erraticism  passes  over  into  irresponsibility  may  be  diffi- 


170  INSANITY. 

cult  to  determine.  These  patients  are  extremely  sus- 
ceptible to  outside  influences,  are  impressionable,  and 
those  from  the  lower  walks  of  life,  from  which  their 
numbers  are  largely  recruited,  prove  the  ready  tool  of 
anarchists,  revolutionists,  and  those  who  would  subvert 
social  order.  In  the  early  stages  of  the  malady  there 
are  persecutory  delusions,  and  in  consequence  of  these, 
dangerous  tendencies  suddenly  develop.  Reasoning 
may  be  of  a  logical  character,  and  the  delusions  not 
intrinsically  unbelievable,  as,  for  example,  that  a  hus- 
band known  to  be  consorting  with  lewd  women  is  at- 
tempting to  poison  his  wife.  If,  however,  the  wife 
should  express  the  belief  that  poison  was  administered 
by  shaking  garments  in  her  room,  or  that  it  was  mailed 
to  her  in  papers  dusted  over  with  impalpable  powder, 
its  essentially  delusional  character  would  be  apparent. 
The  medical  examiner  should  preserve  an  open  mind 
and  not  permit  himself  to  be  misled  by  the  apparent 
reasonableness  of  what  are,  in  fact,  but  morbid  sus- 
picions. 

Psychological  Analysis : — 

Sensation  unaffected. 

Perception  unaffected,  as  a  rule.  Occasionally  hallu- 
cinations occur. 

Memory  unimpaired. 

Organic  Memory  and  Personality  changed. 

Ideation  unimpaired. 

Reasoning  and  Judgment. — No  incoherence  in  group- 
ing of  concepts,  but,  reasoning  from  false  premises,  a 
logical  delusion  results. 

Emotions,  in  persecutory  stage,  painful ;  after  transi- 
tion period,  as  a  rule  pleasurable. 

Attention  unaffected. 


INSANITY.  171 

Will  unimpaired.  Reflexes  unimpaired.  Assaults, 
if  made,  are  because  of  delusions  of  conspiracy  or 
fraud. 

Physical  Symptoms,  immaterial.  There  is  frequently 
a  distinct  lack  of  symmetry  of  the  head. 

There  is  rarely  any  tendency  to  suicide.  Exceptional 
cases,  however,  are  extremely  suicidal.  The  habits  are 
tidy. 

Termination. — Chronicity. 

Treatment. — The  general  principles  outlined  in  Parts 
IV  and  V  of  this  work  apply  to  the  treatment  of  para- 
noia. Employment  is  of  the  utmost  service,  and  under 
the  hospital  regime  much  valuable  work  may  be  ob- 
tained from  these  patients  through  the  tactful  guidance 
of  energies,  which  would  otherwise  be  largely  mis- 
directed, into  useful  channels. 


PART  IV. 


MANAGEMENT    OF    CASES    OF    INSANITY 
FROM  THE  MEDICAL  STANDPOINT. 

IN  former  times  it  was  not  considered  a  matter  for 
reproach  for  a  physician  to  admit  entire  absence  of 
familiarity  with  so-called  mental  disease.  The  state- 
ment, "I  know  nothing  of  insanity,"  was  by  no  means 
infrequent — this,  perhaps,  from  one  appointed  by  the 
court  to  make  an  examination  of  the  mental  condition 
to  determine  the  necessity  for  hospital  treatment,  for 
the  purpose  of  advising  as  to  an  alleged  criminal's  re- 
sponsibility, or  called  to  give  testimony  upon  a  medico- 
legal  question  requiring  expert  opinion.  Now  all  this 
is  changed.  There  is  a  growing  interest  on  the  part  of 
the  general  profession  in  the  subject  of  mental  disease. 
Medical  schools  are  teaching  psychiatry  as  -  a  special 
branch.  Clinics  in  insanity  are  held  in  various  State 
hospitals,  and  the  ability  to  differentiate  forms  of  dis- 
ease becomes  part  of  the  graduate's  equipment. 
Psychopathic  hospitals  for  the  care  of  recent  cases  have 
been  organized  in  different  parts  of  the  country  and 
constitute  an  aid  to  the  teaching  of  psychiatry  in  medi- 
cal colleges. 

It  would  now  be  looked  upon  as  a  confession  of  fail- 
ure to  say,  "This  patient  is  insane,"  without  an  attempt 
at  least  to  classify  the  case.  Just  as  one  called  to  see 
a  patient  with  high  temperature  will  aim  to  discover  the 
reason  for  its  existence,  so  will  the  present-day  practi- 
(172) 


MANAGEMENT    OF    CASES — MEDICAL.  173 

tioner  intelligently  apply  diagnostic  principles  and  place 
the  insane  case  in  its  proper  category.  This  more  seri- 
ous view  will  prove  of  much  practical  benefit  to  pa- 
tients. It  will  hasten  the  coming  of  that  time  when 
antiquated  and  erroneous  notions  of  the  nature  of 
insanity  will  be  abandoned,  sentimental  considerations 
swept  away,  and  cases  of  brain  perturbation  showing 
disturbed  mental  action  as  a  manifestation  viewed  from 
the  same  position  as  are  those  of  pneumonia,  gastritis, 
or  typhoid  fever. 

Called  to  see  a  patient  showing  that  group  of  symp- 
toms to  which  the  collective  term  "insanity"  is  applied, 
the  physician  is  usually  confronted  with  one  of  three 
prominent  conditions  giving  character  to  the  case,  viz., 
mental  excitement  of  varying  degree,  mental  depres- 
sion, or  mental  weakness. 

Excitement  occurs  in  manic-depressive  insanity,  in 
infection  and  exhaustion  psychoses,  in  alcoholic  or  nar- 
cotic delirium,  in  paretic  dementia,  and  episodally  in 
epileptic  states,  in  paranoia,  and  in  the  various  forms 
of  dementia,  organic  and  simple. 

The  physician  will  usually  be  able,  through  inquiry 
into  the  antecedent  condition,  to  assign  the  case  to  its 
appropriate  group.  In  general,  it  may  be  said  that  ex- 
treme agitation,  suspiciousness,  and  painful  emotional 
states  accompanying  excitement  argue  -the  existence  of 
the  depressed  phase  of  manic-depressive  insanity,  and 
self-satisfaction,  mental  exaltation,  pleasurable  emo- 
tions with  flight  of  ideas  and  pressure  of  activity,  the 
excited  phase  of  this  form  of  disease.  Excitement  with 
verbigeration,  incoherency  and  auditory  hallucinations 
and  depression  with  katatonic  attitudes,  stupor,  and 
negativism  are  strongly  suggestive  of  dementia  prsecox. 


174  MANAGEMENT   OF   CASES — MEDICAL. 

Paretic  dementia  is  to  be  feared  if,  in  connection 
with  excitement,  there  are  pupillary  changes  and 
muscular  inco-ordination,  and  may  be  suspected  in  the 
absence  of  these  if  there  have  been  previous  mental 
confusion,  extravagant  or  erratic  conduct,  failure  in 
memory,  and  marked  departure  from  the  normal  in 
appreciation  of  the  fitness  of  things,  in  domestic  rela- 
tions, and  in  sense  of  propriety  extending  over  a  period 
of  weeks  or  months.  The  history  of  the  case  should 
be  thoroughly  sifted,  and  any  well-established  or  con- 
tributory cause  of  nervous  breaking  down,  such  as  the 
results  of  injury  or  a  pathological  condition  which 
would,  under  other  circumstances,  require  surgical 
measures,  should  be  sought  out  and  removed,  but  by 
all  means  a  receptive  attitude  should  be. maintained  and 
a  broad  and  comprehensive  view  taken  in  determining 
the  etiology. 

Be  the  diagnosis  what  it  may,  the  indications  for 
treatment  are  clear,  the  object  being  to  reduce  excite- 
ment and  strengthen  self-control.  The  patient  should 
be  placed  in  bed  at  first  and  cared  for  as  if  physically 
ill.  Years  ago  it  was  the  custom  to  give  considerable 
exercise  to  patients  of  this  class,  and  the  fact  should 
not  be  ignored  that  excitement  must  have  vent,  and  to 
repress  it  too  much  is  to  do  the  patient  harm ;  but  of 
late  years  there- is  a  growing  tendency  toward  the  op- 
posite course — the  conservation  of  strength — with  just 
sufficient  exercise  prescribed  to  divert,  amuse,  and 
furnish  change. 

Almost  without  exception,  cases  of  mental  excite- 
ment do  better  in  bed,  in  a  quiet  room  away  from  dis- 
turbing influences,  and  although  it  is  a  difficult  matter 
to  persuade  one  in  mental  elation — conscious  of  ability 


MANAGEMENT    OF    CASES MEDICAL.  175 

to  move  mountains  and  perform  feats  of  great  strength 
— that  he  needs  rest,  the  rest  should  be  given  and  the 
vital  forces  husbanded  as  carefully  as  possible. 

Two  judicious,  level-headed,  quiet,  unobtrusive 
nurses,  one  for  the  day,  the  other  for  the  night,  should 
be  provided  at  once.  These  should  be  accustomed  to 
the  management  of  such  cases,  and  preferably  gradu- 
ates of  a  training  school  of  some  hospital  for  the  in- 
sane. Members  of  the  family  should,  so  far  as  pos- 
sible, be  excluded  from  the  sick-room.  As  a  rule,  their 
presence  is  harmful.  Powers  of  self-control  exercised 
by  the  patient  alone  with  his  nurse  are  often  abdicated 
entirely  in  the  presence  of  near  relatives.  In  the  family 
there  is  too  often  erring  on  the  side  of  overdoing  and 
fussy  attention  and  in  gratifying  morbid  whims. 
Various  impressions  derived  from  the  attitude  and 
manner  of  solicitous  relatives  give  rise  to  uncomfort- 
able sensations  in  the  patient.  He  recognizes,  for 
example,  that  his  mother  is  suffering  from  emotional 
strain  on  his  account,  and  if  not  conscious  of  being  out 
of  health  he  is  amazed — perhaps  annoyed — by  it.  If  so 
conscious,  particularly  if  suffering  from  undue  anxiety 
about  his  condition,  the  concern  of  others  merely  serves 
to  add  to  his  own  load,  and  the  delusion  that  he  brings 
trouble  and  misfortune  upon  his  family  is  liberally 
confirmed.  In  particular,  where  delusions  are  in  exist- 
ence concerning  some  member  of  the  family,  this  in- 
dividual should  keep  out  of  the  patient's  sight.  It  will 
do  no  good  to  one  who  believes  her  husband  dead,  ill, 
or  unfaithful,  to  have  the  unfortunate  object  of  the 
delusion  in  constant  or  frequent  attendance  in  the  sick- 
room. One  cannot  treat  a  disturbed  condition  of  brain 
by  demonstration  of  the  falsity  of  morbid  concepts 


176  MANAGEMENT   OF   CASES — MEDICAL. 

Better  that  delusions  be  ignored  or  denial  of  them  be 
made  only  at  long  intervals,  and  positively  (without 
discussion),  than  to  attempt  to  counteract  them  by  the 
exercise  of  logic  and  argument. 

In  excitement  as  well  as  depression  there  will  fre- 
quently be  found  a  state  of  autotoxic  constipation  and 
imperfect  digestion  with  malassimilation.  Indeed,  to 
make  a  momentary  excursion  into  the  realm  of  prophy- 
laxis, it  is  especially  important  to  combat  the  tendency 
to  constipation  so  prevalent  among  the  American  peo- 
ple, especially  American  women.  An  incredibly  large 
percentage  of  nervous  disease  owes  its  existence  to 
neglect  of  the  bowels.  It  should  be  impressed  upon 
patients  that  grave  dangers  to  health  lurk  in  irregu- 
larity in  this  function,  and  when  constipation  is  in 
existence,  systematic  efforts  should  be  made  to  over- 
come it  through  calisthenic  exercises,  liberal  potations 
of  hot  water  before  breakfast,  and  abdominal  massage. 
We  are  on  vastly  better  ground  for  the  comprehension 
and  scientific  treatment  of  this  condition  than  ever 
before,  owing  to  the  development  of  the  theory  of 
auto-infection.  In  constipation  attendant  upon  insane 
states  there  is  no  remedy  so  good  as  calomel  given  in 
sufficient  doses  for  thorough  results.  Thereafter  the 
bowels  should  be  kept  in  a  soluble  condition  by  the  use 
of  the  effervescent  salts,  aperient  waters,  fluid  laxatives 
— whatever  the  patient  can  be  induced  to  take  and  finds 
most  agreeable,  the  calomel  to  be  repeated  when  the 
coated  tongue,  foul  breath,  and  general  phenomena  of 
impaired  action  of  the  stomach  and  intestinal  canal 
give  occasion  for  its  use.  A  valuable  drug  for  use 
in  this  condition  is  the  effervescent  phosphate  of 
sodium. 


MANAGEMENT    OF    CASES — MEDICAL.  177 

I  have  elsewhere  said :  1  "The  theory  of  autotoxis 
as  a  causative  factor  in  the  psychoses  and  neuroses  has 
furnished  a  working  basis  for  the  explanation  of  cer- 
tain departures  from  the  normal  in  the  cerebrospinal 
sphere  of  activity.  That  the  theory  has  been  over- 
loaded, possibly  goes  without  saying.  This  is  unfor- 
tunately true  of  every  illuminating  theory,  but  many 
pursuing  the  treatment  of  nervous  and  mental  maladies 
are  reasonably  well  assured  that  deductions  from  the 
favorable  action  of  eliminatives  post  hoc  justify  the 
further  propter  hoc  assumption  of  the  causative  rela- 
tion of  retained  toxins  to  nervous  perturbation. 

"Constipation  is  a  bane  of  mankind  and  seems  un- 
avoidable under  present-day  conditions  of  living  and 
work.  It  is  especially  the  bane  of  womankind,  and  is 
often  developed  at  an  early  period  of  life  through  in- 
adequate or  indecent  toilet  facilities  in  the  public 
schools.  'We  have  taken  your  advice  and  built  our 
new  school-house  around  the  water-closet,'  said  an  ex- 
perienced member  of  a  Board  of  Education  to  the 
writer  on  one  occasion. 

"Constipation  is  indubitably  a  factor  in,  if  not  the 
ultimate  cause  of  a  frightfully  large  proportion  of 
mental  cases.  Its  correction  and  the  relief  of  incidental 
malassimilation  are  ends  to  which  the  experienced 
psychiatrist  directs  early  effort.  Realizing  the  impor- 
tance of  elimination,  it  is  impossible  to  refrain  from  a 
congratulatory  expression  to  the  author  of  this  book 
for  his  painstaking  directions  for  the  medical  relief  of 
intestinal  torpor.  Symptomatically  the  nervous  case  is 

1  Under  the  heading  "Psychopathic  Nephroenteroptic 
Symptomatology,"  in  the  book  of  Dr.  H.  W.  Longyear,  of 
Detroit,  on  "Nephrocoloptosis." 

12 


178  MANAGEMENT   OF    CASES MEDICAL. 

invariably  improved  by  skilful  attention  to  abdominal 
conditions  arising  from  constipation.  Is  your  mental 
patient  restless — attend  to  the  bowels.  Is  he  irritable — 
attend  to  the  bowels.  Acquaint  yourself  with  the  con- 
dition of  the  teeth,  the  ears,  the  eyes,  the  chest  organs, 
the  kidneys — but  incidentally  unload  the  bowels.  Is 
he  sleepless — see  that  the  bowels  are  active.  Is  he 
lacking  appetite — empty  the  bowels.  In  the  experience 
of  the  writer  the  best  hypnotic  is  often  a  dose  of  castor 
oil,  and  the  best  tonic  a  colon  flushing.  Elimination 
and  again  elimination — toujours  elimination  should  be 
the  watchword  in  the  treatment  of  morbid  mental 
states. 

"It  is  probable  that  fecal  impaction  of  large  amount 
is  a  more  frequent  condition  than  is  generally  recog- 
nized. Experience  in  many  cases — one  very  recent — 
indicates  that  impaction  may  be  present  in  extreme 
degree  without  obvious  abdominal  indications  pointing 
to  colonic  distention.  Nurses  may  be  deceived  by  the 
appearance  of  regularity  in  patients'  stools,  while 
emptying  the  intestinal  canal  at  higher  levels  than  the 
sigmoid  does  not  occur.  When  through  well-directed 
effort  this  finally  takes  place  the  amount  of  fecal  ac- 
cumulation may  be  astounding. 

"That  perverted  emotional  states  in  relatively  healthy 
individuals  may  be  induced  by  temporary  bowel  in- 
activity needs  no  demonstration  to  one  habitually 
regular  in  this  function.  Prevented  from  its  perform- 
ance, there  are  irritability,  hebetude,  lassitude,  malaise, 
vasomotor  perturbation:  the  person's  mental  output 
is  indifferent  and  his  emotional  responsiveness  is.  un- 
stable. Add  to  the  sensations  thus  induced  the  results 
of  months  or  years  of  habitual  constipation,  and  it  is 


MANAGEMENT    OF    CASES — MEDICAL.  179 

not  difficult  to  understand  how  morbid  habits  of  think- 
ing may  be  augmented,  if  not  engendered,  by  chronic 
bowel  torpor." 

Further  experience  emphasizes  the  importance  of  the 
principles  laid  down  in  the  above  declaration.  No 
remedies  have  so  important  bearing  upon  the  treatment 
of  morbid  mental  conditions  as  those  of  this  class. 
Many  a  patient  is  relieved  from  profound  depression 
through  the  daily  laxative  or  enema  or  both.  Many 
an  outbreak  of  excitement  is  modified  or  averted  by 
active  purgation.  Constant  vigilance  to  meet  the  con- 
dition of  constipation  is  necessary.  As  to  the  particular 
laxative,  it  matters  less  than  that  one  which  is  efficient 
shall  be  administered.  My  preference  is  for  the  salines 
(Abilena  Water,  Hunyadi  Water,  Seidlitz  powders, 
effervescing  citrate  of  magnesium)  before  breakfast, 
castor  oil  at  night  or  at  any  convenient  time  during  the 
day,  calomel  in  the  large  single  dose  of  3  grains  and 
followed  by  a  saline;  lastly,  the  compound  cathartic 
and  the  improved  compound  cathartic  pill  of  the 
Pharmacopoeia.  It  cannot  be  said  of  cathartics,  as 
some  evilly  inspired  person  has  said  of  whisky,  that 
some  kinds  are  better  than  others,  but  that  all  are 
good.  Cascara  is,  in  my  opinion,  practically  valueless. 
It  is  not  adapted  to  those  states  of  visceral  torpor  prev- 
alent in  mental  diseases.  Supplied  with  it  week  after 
week,  a  tolerance  is  established.  It  is  perhaps  the  most 
readily  accepted  of  any  of  the  pharmaceutical  prepara- 
tions of  a  laxative  character — this  because  of  the  nice- 
ties developed  in  its  manufacture  and  the  agreeable 
character  of  the  preparations  which  the  pharmaceutists 
have  put  out. 

The  remedy  petrolatum,  given  as  advised  by  Long- 


180  MANAGEMENT    OF    CASES MEDICAL. 

year,  has  been  found  serviceable  in  certain  neurasthenic 
states.  I  quote:1  "For  this  purpose  the  author  has 
found  nothing  else  which  serves  the  purpose  as  satis- 
factorily in  most  cases  as  the  so-called  'petrolatum  oil/ 
or  liquid  vaselin.  The  properly  prepared  oil  should 
be  tasteless,  nearly  clear — not  amber  colored — and 
should  be  thick  and  heavy  in  consistency.  The  thin  oil, 
which  is  used  largely  as  a  medium  in  spray  medication, 
is  not  suitable  for  this  purpose.  The  preparation  is 
chemically  paraffin,  and  not  a  fat,  as  its  name  would 
signify,  and  consequently  does  not  saponify  with  alka- 
lies, or  become  digested  or  altered  in  passing  through 
the  alimentary  tract.  It  is  this  quality  which  causes 
it  to  act  in  a  mechanical  way  only,  passing  through  the 
stomach  and  small  intestines  unchanged,  and  then  into 
the  colon,  where,  by  mixing  with  fecal  matter  and  coat- 
ing the  mucous  membrane,  the  effectiveness  of  peri- 
stalsis is  augmented;  the  contents  of  the  bowel  pass 
over  the  angulations  with  a  minimum  amount  of  effort 
and  irritation,  to  the  subsequent  comfort  of  the  patient. 
The  dose  is  usually  one  tablespoonful  taken  clear  twice 
daily  on  an  empty  stomach.  The  author  usually 
directs  one  dose  to  be  taken  late  in  the  afternoon,  about 
an  hour  before  the  evening  meal,  and  the  other  at 
bedtime.  The  effect  of  this  oil  is  usually  sufficient  to 
cause  the  contents  of  the  bowel  to  pass  into  the  de- 
scending colon  and  in  some  cases  to  result  in  regular 
and  satisfactory  defecation." 

It  is  quite  evident  that  certain  principles  of  treatment 
which  are  considered  important  in  hospitals  are  diffi- 
cult of  application  elsewhere,  and  what  to  do  for  the 


1  "Nephrocoloptosis,"  C.  V.  Mosby  Company. 


MANAGEMENT   OF   CASES — MEDICAL.  181 

insane  in  private  care  often  presents  itself  as  a  perplex- 
ing problem.  Surrounded  by  anxious  friends  and  curi- 
ous neighbors,  the  patient  noisy,  the  house  in  commo- 
tion, and  the  circumstances  such  as  to  call  forth 
irresponsible  comment,  criticism,  or  censure,  it  is  diffi- 
cult for  the  physician  to  remain  indifferent  to  the 
clamor  for  medicine  to  produce  quiet.  It  can  be  said, 
however,  positively  and  without  qualification,  that 
remedies  directed  to  subduing  the  patient,  depressing 
drugs,  hyoscyamine,  conium,  tartar  emetic  (recom- 
mended in  a  textbook,  but  I  fancy  seldom,  if  ever, 
employed),  the  bromides,  do  no  permanent  good  and 
are  often  productive  of  harm.  The  quiet  they  bring 
about  is  at  the  expense  of  strength.  It  should  not  be 
forgotten  that,  however  much  strength  may  be  mani- 
fested in  excitement,  this  is  largely  fictitious.  To  re- 
strain muscular  activity  by  the  use  of  drugs  is  not 
curative.  There  is  brain  exhaustion  to  deal  with  and 
the  rapid  combustion  of  nervous  tissues  must  be  met 
by  sustaining  remedies  and  those  which  promote  nutri- 
tion rather  than  by  those  which  lower  the  heart's  action 
or  act  directly  as  paralyzers  of  muscular  activity.  In 
the  daytime,  therefore,  it  should  rarely  be  attempted  to 
produce  sleep  by  the  use  of  drugs.  Natural  sleep — that 
which  comes  spontaneously  or  follows  a  hot  bath,  a 
glass  of  malted  milk,  or  a  salt  glow  and  massage — 
should  be  favored  at  all  times,  whether  day  or  night, 
but  hypnotic  drugs  should  be  avoided  if  they  can  pos- 
sibly be  dispensed  with,  and  should  be  used,  when 
necessary,  only  at  night.  As  a  pure  sleep  producer,  I 
know  'of  no  drug  equal  to  hydrated  chloral,  and 
singularly,  although  all  my  life  I  have  heard  of  the 
chloral  habit  and  of  chloral  dependence,  I  have  never 


182  MANAGEMENT    OF    CASES MEDICAL. 

encountered  a  case  of  it.  I  have  never  known  its  use 
to  create  a  craving,  or  its  withdrawal,  when  the  nerv- 
ous system  was  restored  to  the  point  to  permit  it,  to  be 
followed  by  sleeplessness  attributable  to  the  with- 
drawal. Its  use  is  open  to  objection  wbere  there  is 
feebleness  of  the  heart,  but  even  in  such  cases  where 
this  is  not  extreme,  its  effects  are  happy,  and  cardiac 
depression  can  frequently  be  counteracted  by  the  use 
of  quinine.  A  15-  or  20-  grain  dose  of  chloral  hydrate 
is  as  large  as  it  is  well  to  prescribe.  Sometimes  to  this 
a  few  minims  of  fluidextract  of  hyoscyamus  or  a  tea- 
spoonful  of  elixir  valerianate  of  ammonia  may  be 
added;  or  the  bromidia  may  be  substituted.  Usually 
there  should  be  no  occasion,  if  the  patient  has  been 
sufficiently  and  properly  fed  and  cared  for  during  the 
day,  to  repeat  the  dose  more  than  once  three  or  four 
hours  after  the  exhibition  of  the  first. 

When  sleep  fails  to  appear  after  this  medication, 
resort  to  other  means  is  preferable  to  repetition  of  the 
dose.  Kraepelin  speaks  of  death  following  a  5-gram 
dose  of  chloral  hydrate.  This  is  quite  probable.  How- 
ever, never  having  given  to  the  same  patient  more  than 
60  grains  in  divided  doses  (and  this  in  rare  instances) 
in  one  night,  I  am  unprepared  to  confirm  from  personal 
experience  an  expression  concerning  a  lethal  dose.  The 
use  of  chloral  in  the  epileptiform  seizures  of  paretic 
dementia,  with  the  exceptional  case  in  which  untoward 
results  were  obtained,  and  the  abuse  of  chloral  giving 
in  alcoholism,  have  been  discussed  under  these  heads, 
respectively.  In  status  epilepticus  it  is  useful  given  by 
rectum  in  conjunction  with  the  bromides. 

Paraldehyde  is  an  all-round,  frequently  available,  and 
practically  danger  free  drug.  Under  1  or  2  drams,  re- 


MANAGEMENT    OF    CASES — MEDICAL.  183 

peated  in  two  hours  if  necessary,  quiet,  restful  sleep  is 
apt  to  occur.  It  is  objectionable  to  the  palate,  but  its 
remote  effects  are  happy  and  the  warmth  and  glow 
following  ingestion  so  immediate  and  constant  that 
the  danger  of  establishing  dependence  upon  it  should 
be  borne  in  mind.  The  drug  has  a  wide  range  of 
utility. 

Sulfonal,  veronal,  and  trional  are  also  excellent 
sleep-producers,  and  in  some  cases  supply  a  want  that 
chloral  does  not  meet.  In  neurasthenic  states  and  in 
the  agitated  forms  of  manic-depressive  insanity  they 
are  especially  useful.  Their  good  effect  wears  out, 
however,  and  they  are  not  well  suited  to  nightly  ad- 
ministration for  any  length  of  time.  They  are  best 
given  in  hot  milk,  and  if  merely  the  suggestion  of  a 
hypnotic  is  required,  beta-naphthol  may  be  substituted. 

In  a  hitherto-reported  case  of  morphine  addiction  in 
which  there  was  undoubtedly  some  idiosyncrasy,  the 
prolonged  somnolence  following  a  moderate  dose  of 
sulfonal  mitigated  very  materially  the  discomforts  at- 
tendant upon  the  withdrawal  of  the  accustomed  nar- 
cotic. It  is  especially  true  of  sulfonal  that  the  "hold- 
over" effects  are  considerable  and  dullness  occurs  on 
the  day  following  its  administration,  which  interferes 
materially  with  the  psychomotor  output.  However,  in 
connection  therewith  the  measure  of  emotional  blunting 
may  contribute  to  the  patient's  comfort  temporarily. 

There  are  cases — rare  indeed — that  demand  and  are 
benefited  by  an  occasional  dose  of  morphine,  codeine, 
or  some  extractive  of  opium.  It  goes  without  saying 
that  the  administration  of  any  of  these  medicines 
should  be  extremely  infrequent,  both  because  of  the 
danger  of  habit  formation  and  the  increase  in  bowel 


184  MANAGEMENT    OF    CASES MEDICAL. 

torpor,  their  inevitable  accompaniment.  The  cases 
benefited  are  those  of  acute  agitation, — frenzy, — where 
there  is  great  distress  and  where  painful  delusions  lead 
to  the  refusal  of  food  and  to  suicidal  acts,  and  forbid 
sleep.  The  remedies  kola,  coca,  strychnine,  quinine, 
capsicum,  valerianate  of  ammonia,  dogwood,  are  all 
of  value  in  the  treatment  of  habit  cases  and  are  else- 
where discussed.  In  exhaustive  states  attended  with 
flushed  face,  muttering,  shifting  hallucinatory  impres- 
sions, furred  tongue,  sordes  on  the  teeth,  faucial  dry- 
ness,  in  short,  a  typhoid  condition  sine  typhoid,  the 
use  of  strychnine  hypodermically,  and  the  normal  salt 
solution  and  quinine  by  the  rectum,  is  most  desirable. 
Coincident  with  their  employment  there  frequently  ap- 
pear improvement  in  the  pulse,  temperature  reduction, 
increased  flow  of  urine,  and  willingness  to  accept 
nourishment.  These  remedies  in  connection  with  care- 
fully managed  hydrotherapy — topical  cool  sponging, 
cold  applications  to  the  head — bring  relief  to  conditions 
which  occasion  great  anxiety. 

As  a  sedative  pure  and  simple  there  is  now  and  then 
indication  for  hyoscine  hypodermically.  For  the  com- 
fort of  the  patient  and  the  repose  of  the  household  its 
use  may  be  unescapable.  It  must  be  rare,  however,  that 
necessity  shall  arise  for  its  administration.  Fortu- 
nately, there  are  hydrotherapeutic  measures  in  vogue  in 
recent  years  that  quite  fully  take  the  place  of  that 
"chemical  restraint"  much  denounced  by  reformers  of 
a  few  decades  ago  who  felt  called  upon  to  voice  their 
opposition  to  it  in  tones  implying  that  they  alone  were 
righteous  and  their  neighbors  not  half  as  good  as  they 
should  be.  It  is  perhaps  sufficient  to  say  that  in  this 
day  and  age  the  potential  prescriber  of  a  sedative 


MANAGEMENT   OF    CASES MEDICAL.  185 

designed  to  modify  excitement  and  bring  about  tempo- 
rary motor  inadequacy  will  think  twice  and  perhaps 
again  before  resorting  to  the  convenient  little  tablet  and 
hypodermic  syringe  and  will  direct  that  his  patient  be 
given  a  prolonged  bath  of  hours'  duration  in  water  at 
a  uniform  temperature  of  100°  F.  It  is  more  than 
likely  that  in  most  well-ordered  hospitals  for  the  insane 
at  the  present  time  the  supply  in  hand  of  hyoscine  tab- 
lets has  undergone  a  degree  of  deterioration  through 
age  that  noticeably  interferes  with  their  solubility. 

In  advocating  bed  treatment  of  recent  cases,  I  would 
not  be  understood  as  being  opposed  to  giving  such  cases 
as  are  physically  able  to  bear  it  a  moderate  degree  of 
exercise  in  the  open  air.  If,  however,  confusion  and 
excitement  are  not  relieved,  or  are  increased  by  exer- 
cise, it  should  be  omitted. 

Tonics  and  remedies  to  promote  tissue  building  are 
needed.  The  bitter  tonics  and  strychnine,  capsicum 
and  nux  vomica,  iron  preparations,  the  mineral  acids, 
the  hypophosphites,  malt  preparations,  all  are  valuable 
in  selected  cases.  Eggnog  and  milk  punch,  containing 
from  ^  to  1  ounce  of  whisky,  will  be  needed  occa- 
sionally, and  whisky  or  brandy  in  small  and  frequently 
repeated  doses  is  valuable  in  exhaustive  states.  A 
good  indication  for  the  withdrawal  of  alcohol  is  dis- 
turbance of  the  vasomotor  system  indicated  by  flushing 
of  the  face  soon  after  its  administration.  Quinine  is 
an  indispensable  agent  in  exhaustive  states,  and  may 
be  given  in  2-  or  3-  grain  doses  per  mouth  or  by  the 
lower  bowel  from  time  to  time,  according  to  circum- 
stances. 

The  exhibition  of  thyroid-gland  extract,  desiccated 
(P.  D.  &  Co.),  was  followed  by  distinct  betterment 


186  MANAGEMENT   OF    CASES MEDICAL. 

in  a  case  of  dementia  prsecox  of  the  katatonic  type. 
Coincident  with  the  acquirement  of  much  flesh  there 
were  in  this  case  dullness,  irritability,  and  episodal  out- 
breaks of  violence.  On  occasions  as  much  as  10  grains 
t.  i.  d.  were  given.  This  resulted  in  rather  rapid  loss  of 
weight.  Five  grains,  on  the  contrary,  did  not  seriously 
interfere  with  nutrition  and  promoted  composure  and 
emotional  stability.  It  is  desirable  to  discontinue  from 
time  to  time  the  giving  of  this  remedy,  resuming  its 
administration  after  intervals  of  one  or  two  weeks. 

If  restlessness,  excitement,  suspiciousness,  or  irrita- 
bility are  such  as  to  generally  demand  more  than  the 
manual  restraint  of  one  person,  it  will  in  all  probability 
be  the  better  plan  to  place  the  patient  in  some  hospital 
for  the  care  of  the  insane.  Indeed,  in  the  vast  majority 
of  cases  of  mental  excitement  patients  do  better  in 
hospitals  than  at  home.  At  home  the  environment  is 
that  to  which  the  patient  has  been  accustomed  and  with 
which  delusions  are  associated.  Again,  it  is  extremely 
difficult  for  the  physician  to  secure  obedience  to  pre- 
scribed regulations,  owing  to  the  injudicious  inter- 
ference of  anxious  relatives ;  and  still,  again,  that  ideal 
nurse  who  shall  be  familiar  with  the  care  of  the  insane, 
tactful,  considerate,  and  attentive,  who  will  leave  noth- 
ing undone  or  unspoken  which  will  be  productive  of 
good,  but  who  will  omit  that  which  is  irritating  to  the 
patient,  is  not  always  obtainable  on  short  notice.  In 
hospitals  he  is  numbered  by  scores,  and  it  goes  without 
saying  that  his  services  are  retained  if  possible.  There 
are  cases  of  acute  psychoses  attended  by  delirium  which 
should  never  be  removed  from  home,  and  in  the  deci- 
sion of  the  question  of  removal  the  physician  will  often 
require  to  exercise  a  wise  and  discriminating  judg- 


MANAGEMENT    OF    CASES MEDICAL.  187 

ment ;  but  it  must  at  least  be  better,  as  a  rule,  in  case 
means  of  control  at  home  are  insufficient  without  re- 
sorting to  mechanical  restraint,  to  place  the  patient 
where  the  surroundings  savor  of  sustaining  discipline, 
and  where  the  influence  of  superior  numbers  is  before 
him  constantly. 

The  quality  of  mental  depression  which  is  encoun- 
tered by  the  examiner  in  his  investigation  of  a  case 
presented  may  be  at  once  suggestive  of  the  form  of 
disease  and  an  aid  to  early  diagnosis.  Depression  with 
self-centering,  misgivings,  doubts  as  to  the  expediency 
of  any  plan  suggested  or  effort  put  forth  with  hope- 
lessness and  self-disparagement — occurring  in  the  in- 
volutional  period  of  life  and  attended  with  visceral 
illusions — points  to  presenile  melancholia. 

Depression  with  negativism,  torpor,  mutism,  kata- 
tonic  manifestations  and  depression,  with  emotional 
states  suddenly  shifting  to  those  of  elation,  suggests 
dementia  praecox. 

Depression  with  pupillary  abnormalities  points 
strongly  to  paretic  dementia. 

The  manic-depressive  depression  is  accompanied  by 
impressions  of  extreme  unworthiness,  of  sinfulness  and 
the  fear  of  punishment  here  and  hereafter.  The  suici- 
dal impulse  is  strong. 

The  leading  characteristics  of  the  depression  of 
paranoia  are  suspiciousness  and  persecutory  delusions. 

The  treatment  of  mental  depression  does  not  differ 
widely  from  that  laid  down  already.  In  depression 
much  better  opportunity  is  afforded  for  satisfactory 
attention  to  any  local  disorder,  for  the  use  of  high 
enemata,  the  employment  of  massage,  and  the  bestowal 
of  valuable  nursing  attention,  than  in  excitement,  but 


188  MANAGEMENT   OF   CASES MEDICAL. 

treatment  is  much  the  same  in  the  two  conditions.  In 
depression,  however,  there  will  be  greater  need  for  the 
use  of  remedies  directed  to  improving  the  circulation 
and  stimulating  peristalsis.  Certain  drugs,  like  kola, 
coca,  and  caffeine,  are  useful  also  in  painful  emotional 
states.  I  have  never  had  much  success  in  the  employ- 
ment of  cannabis  indica,  and  for  obvious  reasons  rarely 
prescribe  any  of  the  alkaloids  of  opium.  They  are, 
however,  of  distinct  service  in  exceptional  cases,  as  has 
been  already  indicated.  The  static  electrical  breeze  is 
of  great  value,  given  just  before  bedtime,  for  its  sooth- 
ing and  hypnotic  quality. 

I  am  no  friend  of  the  bromides  in  the  treatment  of 
depression  and  rarely  advise  their  use  in  other  than  the 
epileptic  and  epileptiform  states.  For  the  neurasthenic 
headache  a  simple  prescription  of  elixir  of  valerianate 
of  ammonia  and  aromatic  spirit  of  ammonia  is  often 
useful.  For  the  daily  tonic  prescription  and  for  the 
night  hypnotic  "that  remedy  you  call  placebo"  will  be 
found  in  the  end  most  frequently  advantageous  to  both 
sufferers — the  one  who  receives  and  the  one  who  pre- 
scribes. 

In  the  frequent  cases  of  depression  where  a  heart 
tonic  is  needed  I  have  found  the  combination  cereus 
grandiflorus,  niv;  tinct.  digitalis,  TH.J  ;  citrate  of  caf- 
feine, gr.  j,  of  which  a  tablet  is  manufactured  by  most 
of  the  high-class  pharmaceutists,  exceedingly  valuable. 

The  salt  glow  alluded  to  heretofore  is  beneficial  in 
promoting  elimination  and  improving  general  nutrition. 
After  a  thorough  perspiration  is  induced,  as  in  the 
Russian  bath,  fine  salt  is  rubbed  on  the  body  and  a 
cold  shower  follows.  In  addition  to  this,  electro-mas- 
sage administered  by  the  usual  methods  is  beneficial. 


MANAGEMENT    OF    CASES MEDICAL.  189 

When  the  patient  will  permit  the  attention  without 
undue  excitement,  and  there  are  indications  for  their 
use,  high  enemata  may  be  resorted  to  every  other  day 
to  insure  the  perfect  emptying  of  the  large  intestine. 
Indeed,  a  simple  enema  will  usually  be  required  early 
in  the  case,  and  from  time  to  time  later,  with  or  with- 
out the  patient's  co-operation.  Faecal  impaction  is  by 
no  means  an  infrequent  condition,  and  immediate  im- 
provement and  increase  of  comfort  may  come  through 
relieving  it.  Enemata  should  be  composed  of  soap- 
suds, to  which  may  be  added  turpentine,  oil,  or  glyc- 
erin, as  indicated.  Sufficient  help  should  be  present 
to  prevent  the  patient  from  struggling  and  to  insure 
against  injury.  This  point  is  emphasized  because  of  a 
painful,  and  in  its  results  fatal,  accident  which  I  once 
knew  to  attend  the  administration  of  an  enema.  Either 
in  consequence  of  a  fistulous  opening  at  the  anus,  or  of 
a  friable  condition  of  the  rectal  walls,  an  enema  was 
once  in  my  experience,  many  years  ago,  introduced  into 
the  cellular  tissue  about  the  rectum.  The  assistance  of 
vision  in. enema-giving  may  be  imperatively  necessary. 
The  temperature  of  the  liquid  must  be  taken  by  the 
thermometer,  and  every  precaution  adopted  to  protect 
the  patient  from  injury. 

The  heavy  oil  of  petrolatum,  of  which  a  tablespoon- 
ful  may  be  given  in  orange  juice  night  and  morning,  is 
an  excellent  remedy  in  obstinate  constipation.  The 
normal  salt  solution  in  amounts  from  6  to  8  ounces 
every  four  hours,  by  the  bowel,  is  of  great  service  in 
relieving  faecal  impaction. 

It  is  no  less  important  that  the  function  of  the  kid- 
neys and  bladder  be  looked  into  daily,  and  the  catheter 
passed  when  urination  is  tardy  or  insufficient.  Patients 


190  MANAGEMENT    OF    CASES MEDICAL. 

who  are  inattentive  frequently  permit  the  bladder  to 
become  distended,  rendering  it  exceedingly  liable  to 
rupture. 

In  mental  excitement  good  may  be  accomplished  in 
many  cases  by  the  application  of  the  ice-cap  to  the 
head,  or  the  head  and  spine,  and  the  hot-water  bag  to 
the  feet.  This  treatment  is  especially  valuable  in  those 
acute  exhaustive  cases  showing  dry  mouth,  flushed 
face,  rapid  pulse,  and  elevation  of  temperature.  In 
connection  with  these  applications,  strychnine  hypo- 
dermically  is  indicated.  This  treatment,  conjoined 
with  the  use  of  general  tonics  and  judicious  feeding,  is 
often  found  efficacious  even  in  highly  unpromising 
cases. 

My  experience  with  the  use  of  the  cold  pack  has 
been  limited.  In  certain  cases  of  paretic  excitement  its 
employment  has  been  of  distinct  service.  In  the  use 
of  cold  water  otherwise  I  have  had  a  varied  and  satis- 
factory experience.  In  sthenic  maniacal  states  the  hot 
bath,  with  cold  affusions  to  the  head  and  subsequent 
cool  sponging,  or  the  cool  sponging  alone,  are  grateful 
to  the  patient  and  of  direct  curative  value. 

Prolonged  baths  in  water  of  a  temperature  of  100° 
F.  furnish  one  of  the  most  important  of  modern 
methods  in  the  allaying  of  excitement  in  sthenic  manic- 
depressive  and  dementia  prsecox  cases.  They  have 
been  recommended  also  in  paretic  excitement,  but  my 
experience  with  their  use  in  this  form  of  disease  has 
been  unsatisfactory.  The  patient's  body  should  be 
anointed  with  vaselin  before  he  is  placed  in  the  bath. 
No  restraint  should  be  exercised.  Permit  the  patient 
to  move  about,  to  sit  up,  or  recline  in  the  bath,  and 
to  splash  water  at  will.  He  will  ordinarily  become 


MANAGEMENT   OF    CASES MEDICAL.  191 

quiet  before  long  and  will  display  the  good  effect  of 
the  treatment.  The  bath  may  be  of  many  hours — in- 
deed for  days  continuously — but  I  am  personally  .in 
favor  of  limiting  its  duration  as  a  rule  to  three  or  four 
hours.  Meals  and  lunches  may  be  given  while  the 
patient  is  in  the  water.  It  goes  without  saying  that  the 
presence  of  a  nurse  in  the  room  to  prevent  scalding, 
suicide,  or  other  accident  is  indispensable. 

In  recent  years  greater  thought  and  attention  are 
being  given  by  physicians  to  the  non-medicinal  side  of 
treatment  and  mental  therapeutics  has  assumed  an  im- 
portance unknown  to  the  student  of  a  generation  ago. 
To  speak  of  psychotherapy  as  a  "discovery"  is  to  mis- 
represent. It  can  by  no  means  justly  be  proclaimed  as 
such,  but  it  is  nevertheless  true  that  physicians  are  now 
putting  in  practice  voluntarily  and  to  a  greater  extent 
powers  employed  unconsciously  and  to  a  more  limited 
degree  from  the  beginnings  of  the  therapeutic  art. 
Every  uplifting  suggestion,  every  hopeful  prognostica- 
tion, the  gentle  touch,  the  soothing  word — all  these  are 
psychotherapeutic  and  as  such  their  importance  is  not 
to  be  ignored.  The  power  of  the  old-time  family  phy- 
sician lay  not  alone  in  his  ability  to  employ  drugs  and 
in  his  surgical  resourcefulness,  but  also  in  rugged  faith, 
spirituality,  and  a  dominating  personality.  His  expres- 
sions carried  conviction,  and  in  an  age  not  so  strongly 
materialistic  his  Christian  profession  and  practice  gave 
infusion  of  hope  and  strength  and  confidence  to  his 
patient.  One  branch  of  psychotherapeutics — psycho- 
analysis— has  been  mentioned  in  the  discussion  of 
hysteria.  To  cases  of  this  group  and  to  hysteroidal 
complications  in  other  cases  its  methods  may  be  ap- 
plied and  often  with  pronounced  advantage. 


192  MANAGEMENT    OF    CASES MEDICAL. 

The  surgical  care  of  patients  suffering  from  insanity 
should  not  be  neglected  or  omitted,  and  any  focus  of 
irritation,  whether  it  be  a  carious  tooth,  an  aching  corn, 
an  ingrowing  toe-nail,  a  boil,  or  an  abdominal  tumor, 
should  if  practicable  be  removed.  Where  it  is  pos- 
sible to  correct  a  malposition  of  some  internal  organ 
which  interferes  with  nutrition  or  makes  injurious 
pressure,  this  should  be  done.  I  have  elsewhere 
written1  as  follows: — 

"It  follows  logically  that  any  structural  impediment 
to  peristalsis  should,  if  possible,  be  relieved  and  that  if 
relieved,  the  symptoms  dependent  upon  it  will  improve. 
Mechanical  difficulties  (obstructions)  that  surgery  can 
reach  should  be  relegated  to  the  hands  of  the  operator. 
The  writer  has  no  interest  in  that  conception  of  sur- 
gery which  constitutes  it  the  be-all  and  end-all  in  treat- 
ment. Patients  subjected  to  ill-advised  operation  are 
rendered  worse  instead  of  better.  The  efficient  and 
helpful  surgeon  to  nervous  and  mental  cases  must 
needs  repress  the  enthusiasm  for  operating  and  intelli- 
gently apply  common-sense  principles  in  their  care  and 
medication.  Many  cases  recover  after  surgery  when 
the  operation  is  but  an  episode.  A  morbid  condition 
has  been  relieved,  a  focus  of  irritation  removed,  and 
the  patient  is  afforded  a  benefaction  comparable  with 
that  furnished  by  a  dentist  who  extracts  an  aching 
tooth.  In  addition,  the  nursing  attention,  the  pro- 
longed quiet,  the  rest  in  bed  are  all  adjuvants  to  his 
betterment. 

"Again,  mental  and  nervous  cases  recover  where 
obvious  and  palpable  lesions,  as  of  the  pelvic  floor  and 

1  "Nephrocoloptosis,"  Longyear,  page  57. 


MANAGEMENT   OF    CASES — MEDICAL.  193 

uterus,  are  left  uncorrected.  The  writer  has  been 
amazed  at  the  facility  with  which  theoretically  pure 
surgical  cases  from  time  to  time  recover  without  sur- 
gery; on  the  other  hand,  he  has  observed  the  benefi- 
cent results  of  surgical  attention  again  and  again  in 
mental  cases.  Rectification  of  the  position  of  a  dis- 
placed kidney  has  been  contributory  to  the  relief  of 
morbid  depression  in  a  case  upon  which  Dr.  Longyear 
operated  and  in  which  he  and  the  writer  were  jointly 
interested. 

"The  pathological  connection  between  kidney  dis- 
placement and  morbid  mentality  has  been  heretofore 
difficult  of  establishment.  That  the  downward  dislo- 
cation is  due,  according  to  the  ingenious  observations 
of  Dr.  Longyear,  to  a  dragging  on  the  nephrocolic 
ligament — the  primary  fault  being  one  of  displacement 
of  alimentary  and  emunctory  organs,  with  consequent 
embarrassment  to  their  functioning — sheds  a  flood  of 
light  on  the  subject.  The  question  resolves  itself  into 
one  of  impaired  nutrition  and  autotoxis,  and  the 
sequence  of  events  in  their  etiological  bearing  upon 
morbid  processes  in  the  nervous  system  is  made  as 
plain  as  a  pikestaff.-  He  who  runs  may  read  their 
significance." 

Mechanical  feeding  should  be  employed  if  refusal 
of  food  is  absolute  or  there  is  threatened  exhaustion 
from  taking  too  small  amounts.  Feeding  is  best  ac- 
complished by  the  use  of  a  funnel  and  rubber  tube 
tipped  by  a  syringe  nozzle  bearing  a  No.  10  or  12 
catheter.  The  patient  should  be  in  the  sitting  or  semi- 
reclining  position,  the  head  bent  slightly  forward. 
Sufficient  help  should  be  in  attendance  to  prevent  suc- 
cessful struggling.  One  or  other  nostril  will  usually 

13 


194  MANAGEMENT    OF    CASES MEDICAL,. 

be  found  patulous  and  into  it  the  catheter  should  be 
passed  slowly,  care  being  used  at  the  entrance  of  the 
oesophagus  that  the  tube  does  not  slip  forward  into  the 
larynx.  If  possible,  a  timely  act  of  swallowing  on  the 
part  of  the  patient  should  be  availed  of  to  push  the  tip 
of  the  catheter  into  the  oesophagus  from  the  posterior 
pharynx,  where  it  has  been  permitted  to  remain  during 
the  efforts  of  the  patient  to  dislodge  it  by  coughing  and 
retching.  The  tube  should  be  immediately  withdrawn 
if  strident  or  metallic  cough,  strangling  or  cyanosis 
appear,  and  an  effort  should  be  made  to  induce  the 
patient  to  speak  before  the  next  step  in  the  feeding 
process  is  taken.  Spasmodic  action,  resistance,  and  ef- 
forts at  regurgitation  having  mainly  ceased,  the  food 
mixture  of  milk,  broth,  eggs,  or  thin  gruel  is  given 
slowly.  The  quantity  may  be  small  or  considerable,  in 
proportion  to  the  digestive  capacity  of  the  patient  and 
the  amount  retained.  In  exceptional  cases  of  persist- 
ent regurgitation  it  is  desirable  to  introduce  but  a 
very  small  quantity  at  one  feeding.  Every  hospital 
man  of  large  experience  has  met  with  serious — some 
with  fatal — accidents  attending  mechanical  feeding. 
Hence  the  detail  which  has  been  employed  in  describ- 
ing this  usually  simple  and  painless  though  distasteful 
operation. 

OTHEMATOMA. — A  not  rare  occurrence  among  the 
insane  is  the  development  of  othematoma,  "the  insane 
ear."  This  is  a  swelling  due  to  effusion  of  blood  in  the 
substance  of  the  ear  between  the  cartilage  and  its  in- 
vesting membrane.  It  is  usually  due  to  violence,  and 
not  infrequently  develops  from  fistic  encounters.  The 
following  laconic  sentiment  regarding  it,  voiced  by  one 
having  large  experience  in  the  care  of  the  insane,  is 


MANAGEMENT    OF    CASES MEDICAL.  195 

perhaps  secretly  echoed  in  the  hearts  of  many  others. 
"You  all  know  the  history  of  othematoma.  'The  in- 
sane ear'  used  to  be  a  frequent  condition.  In  my  ex- 
perience it  has  become  rare.  Only  once,  on  my  return 
from  vacation,  I  found  in  one  ward  an  epidemic  which 
had  attacked  seven  ears.  It  was  easy  to  obtain  the 
pathological  explanation  of  the  epidemic ;  one  pugilistic 
attendant,  and  the  prompt  imitation  of  the  method 
among  a  few  patients  were  the  cause,  and  its  work  was 
easily  stopped." 

Time  was  when  I  believed  trauma  essential  to  the 
development  of  othematoma.  For  more  than  two  de- 
cades after  entering  hospital  work  I  saw  few1  cases  in 
which  there  failed  the  history  of  injury,  from  without 
or  self-inflicted,  or  some  form  of  accident;  and  in 
those  cases  not  directly  traceable  to  trauma,  I  think  I 
usually  suspected  it.  At  the  end  of  that  time,  however, 
I  was  consulted  by  a  prominent  manufacturer,  leading 
a  strenuous  business  life,  but  not  exposed  to  any 
special  danger.  He  had  othematoma.  The  case  re- 
covered without  deformity.  It  was  in  a  way  a  relief 
that  I  failed  to  find,  after  the  most  painstaking  investi- 
gation, the  history  of  any  injury  whatsoever.  I  made 
all  sorts  of  inquiries  and  suggestions  as  to  how  he 
might  have  bruised  his  ear,  but  he  was  sure  he  had 
not  done  so.  Eventually  the  conclusion  was  necessi- 
tated that,  in  one  case  at  least,  an  othematoma  not  due 
to  trauma  had  occurred.  An  interesting  fact  in  this 
connection  is,  that  several  years  before  this  man  had 
suffered  from  an  attack  of  mental  depression.  He 
fully  recovered,  however,  in  due  time. 

If  the  hematoma  is  small  and  the  swelling  not  very 
tense,  it  may  be  left  to  subside.  The  best  results  which 


196  MANAGEMENT    OF    CASES MEDICAL. 

I  have  ever  seen  in  a  case,  however,  followed  the 
evacuation  of  the  contents  of  the  sac  and  the  applica- 
tion of  pressure.  On  the  subsidence  of  the  swelling 
there  is  apt  to  be  contraction  of  the  ear  and  great  dis- 
figurement. 

The  care  of  the  recent  case  during  convalescence  is 
a  delicate  and  important  matter.  Access  of  friends 
and  relatives  to  the  patient  should  not  be  permitted 
prematurely.  Effort  should  be  directed  through  mas- 
sage, hydrotherapy,  electrotherapy,  calisthenic  exer- 
cises, and  light  physical  employment  adapted  to  his 
capacity,  to  build  up  the  strength  and  promote  cere- 
bral nutrition.  Let  the  patient  vegetate  mentally. 
Cerebral  effort  should  never  be  actively  stimulated,  and 
any  attempts  to  draw  the  patient  out,  to  jolly  him,  to 
excite  his  interest  in  conversation,  are  apt  to  be  con- 
fusing and  provocative  of  relapse.  The  physician  must 
safeguard  such  patients  with  the  utmost  care. 

It  will  be  well  to  hesitate  long  before  advising 
change  of  scene  and  travel  for  neurasthenic  and  de- 
presred  patients.  This  advice  is  frequently  given  and 
often  with  injurious  effect.  Such  patients  do  not  bear 
well  the  introduction  of  new  and  varied  percepts  into 
consciousness,  but  are  fatigued  and  bewildered  by  it. 
Their  lack  of  self-confidence  is  increased  by  unsuccess- 
ful efforts  to  meet  changing  conditions.  Travel  may 
be  suited  to  some  cases,  but  I  am  persuaded  that  it  has 
an  extremely  narrow  range  of  utility. 

The  custodial  care  of  an  insane  person  in  a  sani- 
tarium or  hospital  may  be  necessary  or  expedient.  It 
may  be  necessary  (1)  to  protect  the  patient  from 
himself;  (2)  to  protect  others  from  the  patient.  It 
may  be  expedient  when  not  necessary. 


MANAGEMENT    OF    CASES MEDICAL.  197 

Treatment  away  from  home,  or  in  an  institution, 
often  accomplishes  much  for  the  patient:  this  for  a 
number  of  reasons.  In  the  first  place,  one  is  apt  to 
exercise  greater  self-restraint  among  strangers  or  ac- 
quaintances than  among  relatives.  Latent  powers  in 
this  direction  often  become  active  after  the  transfer 
of  the  patient  from  home.  He  falls  readily  into  the 
discipline  and  regime  of  an  institution,  and  spontane- 
ously displays  powers  of  self-control  not  before  appar- 
ent. The  withdrawal  from  scenes  with  which  former 
delusions  have  been  associated  contributes  to  this. 
Regular  modes  of  life  prescribed  by  others  take  the 
place  of  self-appointed  rules  of  conduct.  The  routine 
itself  is  favorable — there  is  less  to  stimulate,  less  to 
annoy.  In  a  hospital  the  patient  laboring  under  excite- 
ment is  not,  as  too  often  happens  to  one  in  the  care  of 
relatives,  threatened  or  punished  for  disorderly  con- 
duct. If  depressed  he  is  not  adjured  by  everyone  he 
meets  to  "brace  up."  In  a  hospital  he  becomes  less 
introspective.  He  is  thrown  into  the  society  of  those 
similarly  afflicted,  and  finds  that  his  trouble  is  not  more 
deep  and  abiding  than  that  of  his  neighbor.  He  per- 
haps recognizes  in  his  neighbor  a  deluded  condition 
and  can  criticise  in  him  the  conduct  which  springs  from 
morbid  ideas.  Each  may  be  suffering  from  the  same 
general  class  of  delusions,  and  each  recognize  the 
error  of  judgment  in  the  other. 

Removal  from  home  is  often  an  advantage  through 
substituting  a  real  trouble  for  a  fancied  one.  At  home 
the  mind  is  occupied  by  morbid  ideas  to  the  exclusion 
of  everything  else.  Apart  from  familiar  scenes  home- 
sickness perhaps  develops.  As  two  subjects  cannot 
occupy  consciousness  perfectly  at  the  same  time,  there 


198  MANAGEMENT    OF    CASES MEDICAL. 

is  here  substituted  a  healthy  for  an  unnatural  feeling, 
and  a  motive  to  recovery  is  supplied. 

It  is  often  expedient  to  withdraw  the  patient  from 
his  family — this  in  consequence  of  the  influence  of  his 
conduct  upon  the  minds  of  his  growing  children.  The 
example  of  an  insane  member  of  a  household,  and  the 
anxiety  and  worry  attendant  upon  his  care,  are  often 
to  the  last  degree  harmful,  and  tend  to  the  mental  de- 
terioration of  others. 

It  may  be  expedient  to  withdraw  one  from  the  mar- 
ital relation.  There  is,  in  some  forms  of  insanity, 
marked  sexual  excitement,  and  indulgences  growing 
out  of  this  condition  may  prove  a  serious  obstacle  to 
the  patient's  recovery. 

An  insane  person's  removal  from  home  may  be  ex- 
pedient for  the  benefit  of  society.  While  not  actively 
dangerous,  he  may  become  so  under  provocation  or 
through  the  development  of  new  delusions.  Though 
apparently  harmless,  if  he  is  disposed  to  wander  about 
and  indulge  in  eccentricities  of  conduct  and  conversa- 
tion he  becomes  an  annoyance,  and  his  presence  is  de- 
moralizing to  the  community. 


PART  V. 


MANAGEMENT    OF    CASES    OF    INSANITY 
FROM  THE  NURSING  STANDPOINT. 

THE  .  successful  management  of  cases  of  insanity 
necessitates  recognition  of  the  physical  basis  of  mental 
disease,  and  the  direction  of  treatment  to  the  brain,  the 
organ  of  the  mind. 

It  is  the  duty  of  those  having  the  grave  responsibility 
of  caring  for  the  insane  intrusted  to  them  to  have  in 
mind  these  two  great  aims : — 

1.  To  promote  the  recovery  of  patients. 

2.  To  limit  the  amount  of  dementia  in  unrecovered 
cases,  and  thereby  increase  their  well-being  and  happi- 
ness. 

As  every  case  of  mental  disease  is  a  law  unto  itself, 
so  must  each  be  individualized  and  treated  upon  its 
own  merits.  There  can  be  no  wholesale  plan  of  man- 
agement. 

Quickness  of  perception,  kindness,  tact,  and  good 
judgment  are  qualities,  indispensable  to  the  success  of 
an  attendant  of  nurse  upon  the  insane.  Kindness  im- 
plies thoughtfulness,  attentiveness,  conscientious  devo- 
tion: sentiments  which  find  their  reflex  in  judicious, 
well-directed  effort.  Coddling,  demonstrativeness,  and 
display  of  warmth  of  affection  are  always  unnecessary 
and  frequently  detrimental  to  the  interest  of  patients. 
Kindness  should  find  its  chief  expression  in  good 
deeds,  not  in  words. 

(199) 


200  MANAGEMENT   OF   CASES — NURSING. 

In  enumerating  the  desirable  qualities  of  a  nurse,  I 
would  emphasize  the  importance  of  one — the  sense  of 
humor.  Years  of  experience  with  those  in  attendance 
upon  the  insane  has  firmly  fixed  in  mind  the  belief  that 
the  nurse  who  sees  the  amusing  side,  who  notes  her 
patients'  whimsies  and  departures  from  conventional 
standards  of  acting  and  expression  and  derives  amuse- 
ment from  them  is  practically  safe  and  dependable — 
so  far  as  intentional  or  even  impulsive  unkindness  is 
concerned.  If  the  nurse  enjoys  her  patient,  she  will 
do  her  best  possible  in  the  patient's  care  and,  the  deeper 
the  nurse's  penetration  into  the  patient's  moods,  springs 
of  action  and  habits  of  thinking,  the  closer  will  be  the 
rapport  between  the  two  individuals.  The  sense  of 
humor  is  a  saving  grace  in  many  a  complicated 
situation. 

The  recovery  of  patients  is  promoted  by 

1.  Building  up  the  general  health; 

2.  Correcting  pernicious  habits;  and 

3.  Checking  morbid  impulses. 

To  build  up  the  general  health,  there  are  necessary 
good  food,  exercise,  abundance  of  sleep,  and  possibly 
medication. 

The  ADMINISTRATION  OF  FOOD  is  the  most  impor- 
tant duty  of  the  nurse,  and  upon  its  successful  accom- 
plishment everything  depends.  Food  should  be  deli- 
cately prepared,  temptingly  served,  and  presented  to 
the  patient  in  an  inviting  manner.  Dishes  and  utensils 
should  be  scrupulously  clean  and  bright ;  the  tray  cov- 
ered with  a  clean  spread;  a  napkin  provided  for  the 
patient's  use,  which,  in  case  he  is  fed  by  the  hand  of 
another,  should  be  placed  about  his  neck  to  protect  the 
clothing.  Before  giving  food,  the  person  of  the  patient 


MANAGEMENT   OF   CASES — NURSING.  201 

should  be  cleansed,  the  face  sponged,  and  hands  thor- 
oughly cleaned  by  the  use  of  the  nail-brush ;  the  nails 
trimmed.  The  patient  should  have  an  opportunity  to 
rinse  his  mouth  with  cold  water,  and  a  tooth-brush  or 
a  cloth  should  be  used  upon  the  teeth  to  remove  un- 
wholesome accumulations. 

Where  food  is  refused  from  inattentiveness,  as  in 
mental  excitement,  it  is  often  impossible  to  give  more 
than  a  few  spoonfuls  of  liquid  at  a  time.  In  such  cases 
the  administration  of  nourishment  should  be  repeated 
every  hour  or  every  half -hour,  as  may  be,  those  times 
being  selected  during  which  the  patient's  attention  can 
be  gained— when  it  is  the  least  occupied  with  other 
matters.  Inattentive  patients  sometimes  take  food  bet- 
ter at  night,  when  all  is  still,  than  in  the  daytime. 

Where  food  is  persistently  refused  because  of  delu- 
sions— as  in  the  depressed  phase  of  manic-depressive 
insanity — a  careful  study  of  the  patient's  charac- 
teristics and  peculiarities  will  commonly  point  a  way 
to  the  end,  and  resort  to  rectal  alimentation  or  me- 
chanical feeding  will  become  more  and  more,  rare  as 
experience  increases.  Milk  is  an  ideal  food  for  the 
insane,  and  in  debilitated  cases  it  is  often  well  to  give 
it  in  connection  with  egg  and  liquor,  as  in  an  eggnog. 
In  meeting  capricious  and  delicate  appetites,  gruels, 
custards,  broths,  wine- whey, 'beef -tea,  koumyss,  jellies, 
and  fruits  will  all  be  found  of  service.  In  states  of 
acute  exhaustion  or  threatening  exhaustion  attended 
by  unhealthy  conditions  of  the  mouth  and  digestive 
tract,  lemon-juice  or  lemonade  in  small  quantities  is 
often  of  the  greatest  value.  Certain  patients  will  take 
liquid  food  in  small  quantities  where  solid  food  is  al- 
together refused.  A  patient  having  delusions  of  poison 


202  MANAGEMENT   OF   CASES — NURSING. 

may  accept  eggs  boiled  in  the  shell,  or  potatoes  baked 
in  the  skins,  particularly  if  the  cooking  goes  on  in  his 
presence,  naturally  believing  that  no  poison  can  be  in- 
troduced into  these  articles.  One  who  ignores  the  re- 
quest of  his  nurse  or  physician  may  eat  in  obedience 
to  that  of  some  fellow-patient.  Another  will  take  food 
from  the  dining-room  after  the  others  have  left,  pick- 
ing up  something  here  and  there,  who  is  unwilling  to 
eat  in  the  presence  of  others,  or  who  believes  that  he  is 
unworthy  to  be  served  until  they  have  finished.  One 
will  eat  if  left  alone  and  apparently  unnoticed.  An- 
other will  take  food  if  he  can  acquire  it  surreptitiously, 
and  opportunity  should  be  afforded  suspicious  patients 
to  thus  appropriate  it.  One  will  eat  crackers  or  bread, 
or  fruit,  if  placed  in  his  pocket.  Another  will  ex- 
change plates  with  a  neighbor,  and  take  the  food  pre- 
pared for  him,  believing  that  no  poison  has  been  intro- 
duced into  that  particular  plateful.  One  suffering 
from  active  delusions  of  poison  may  accept  part  of  a 
glass  of  milk  if  his  nurse  shows  sufficient  confidence 
in  it  to  drink  a  portion  in  the  patient's  presence.  One 
believing  it  wicked  for  her  to  eat,  will  often  take  food 
if  it  is  forcibly  placed  in  the  mouth — the  least  show  of 
force  being  all  that  is  necessary  to  effect  the  entrance 
of  the  spoon.  Under  this  coercion  she  feels  that  she 
escapes  responsibility  for  the  doing  of  that  which  her 
conscience  disapproves.  In  giving  food,  as  well  as  be- 
stowing other  attentions  upon  suspicious  patients,  an 
affectation  of  indifference  is  often  very  efficacious. 
Under  these  circumstances  a  patient  believes  that  the 
nurse  has  no  personal  interest,  has  no  ends  to  serve. 
Whatever  delusions  or  morbid  impressions  influence 
the  patient,  whether  of  repugnance  to  food  or  delu- 


MANAGEMENT   OF    CASES — NURSING.  203 

sions  of  suspicion  or  poison  or  extravagance  (which 
latter  cause  the  patient  to  believe  that  he  is  of  finer 
fiber  than  those  about  him  and  not  dependent  as  they 
upon  nutritive  substances),  the  careful  nurse  will,  as 
a  rule,  be  equal  to  the  occasion,  and  the  necessity  for 
forced  feeding  will  be  avoided.  There  is  a  wide 
variety  of  liquid  food  of  unquestioned  value  from 
which  to  make  selection;  among  these  milk,  malted 
milk,  Mellin's  food,  broths  of  various  kinds,  and 
Phillips's  digestible  cocoa  are  convenient  for  adminis- 
tration and  adapted  to  weak  digestions. 

Mechanical  feeding  should  be  the  last  resort,  and  the 
operation  invariably  be  performed  by  the  physician. 
It  should  be  borne  in  mind  in  this  connection  that  there 
is  oftentimes  danger  of  overfeeding;  that  where  a 
condition  of  much  debility  exists,  harm  may  be  done 
by  the  introduction  into  the  stomach  at  one  time  of 
what  would  be,  under  ordinary  conditions,  a  proper 
amount  of  food ;  the  assimilative  powers  are  arrested, 
the  secretions  deranged,  and  the  organs  of  digestion  in 
no  condition  to  care  for  it.  For  the  purposes  of  nutri- 
tion in  these  cases  to  give  a  teaspoonful  to  a  table- 
spoonful  of  milk  in  the  natural  way  after  intervals  of 
an  hour  is  better  than  to  administer  a  larger  amount 
artificially.  Milk,  preparations  of  beef,  milk-toast,  and 
other  albuminous  foods  may  be  peptonized  or  pan- 
creatinized — artificially  digested — before  administer- 
ing, and  in  certain  instances  a  purely  liquid  food  may 
be  advantageously  given  by  the  rectum.1 

The  exhibition  of  the  stomach  tube  will  sometimes. 

1  In  certain  cases  this  is  helpful  for  its  moral  effect.  I  have 
known  patients  to  take  food  with  avidity  to  escape  what  they 
regarded  the  humiliation  of  rectal  feeding. 


204  MANAGEMENT    OF    CASES NURSING. 

be  sufficient  to  induce  the  patient  to  take  food.  The 
following  incident  occurred  in  a  Mississippi  asylum. 
Tobe,  a  depressed  patient,  decided  to  end  his  trouble 
by  starving  himself  and  refused  to  eat  for  a  week. 
After  trying  in  vain  to  induce  him  to  take  food,  the 
doctor  called  for  the  stomach  tube  and  was  preparing 
to  feed  him  when  the  following  conversation  took 
place :  Tobe — "Doctor,  what  is  that  thing  you  got 
there?"  Doctor— "A  stomach  tube."  Tobe— "What 
are  you  going  to  do  with  it?"  Doctor — "Feed  you." 
Tobe — "How?"  Doctor — "By  putting  it  down  your 
throat  and  pumping  in  milk."  Tobe — "Doctor,  that 
thing  will  hurt  me."  Doctor — "Yes,  Tobe;  but  we 
can't  afford  to  let  you  starve  and  must  feed  you." 
Tobe  (to  nurse  who  was  holding  a  plate  of  food) — 
"Gimme  that  plate,  I  ain't  no  -  -  fool ;  I  know  when 
to  eat." 

In  the  ADMINISTRATION  OF  MEDICINE  only  the 
smallest  amount  of  force  in  opening  the  mouth  is  justi- 
fiable. It  is.  far  better,  under  ordinary  circumstances, 
to  give  medicine  by  enema  than  to  force  it  into  the 
mouth  and  compel  its  being  swallowed  by  holding  the 
mouth  and  nose— an  expedient  which  is,  I  fear,  too 
frequently  resorted  to,  and  of  which  1  personally  very 
much  disapprove.  In  giving  food  or  medicine  by 
enema,  however,  the  anatomical  relations  of  the  parts 
should  be  borne  in  mind  and  plenty  of  help  provided, 
so  that  no  danger  will  be  encountered  of  doing  the 
patient  injury.  I  have  known  a  fatal  accident  to  occur 
from  the  administration  of  an  enema.  In  the  intro- 
duction of  the  syringe-nozzle  the  assistance  of  vision 
will  be,  in  the  case  of  an  excited  or  frenzied  patient, 
indispensable. 


MANAGEMENT    OF    CASES NURSING.  205 

Medicine  should  be  kept  by  the  nurse  under  lock  and 
key  and  offered  to  the  patient  in  single  doses,  prefer- 
ably in  liquid  form.  I  have  known  a  patient  to  make 
a  "collection  of  aloin,  belladonna,  and  strychnine  tablets 
with  suicidal  intent.  He  cleverly  transferred  them 
from  mouth  to  waistcoat  pocket  after  making  much 
ado  over  swallowing  them  with  the  water  "chaser." 
Tablets  containing  poison  should  be  dissolved  before 
administration.  Accept  no  unlabeled  bottle  and  never 
retain  one  in  the  medicine  closet  if  the  label  is  lost 
or  the  inscription  upon  it  dimmed.  I  have  known  an 
experienced  nurse  to  pour  from  an  Abilena  water 
bottle  an  ounce  of  strong  aqua  ammonia.  Its  odor 
alone  arrested  her  administering  the  dose  to  a  patient. 

PERSONAL  ATTENTION  AND  NURSING. — The  patient 
should  be  kept  tidy  and  neat  at  all  times.  Everything 
about  him — clothing,  bedding,  furniture — should  be 
changed  and  laundered  or  aired  at  frequent  intervals. 
Clothing  and  bedding  must  be  changed  immediately 
if  soiled,  and  the  person  of  the  patient  at  each  chang- 
ing must  be  carefully  bathed.  Do  not  neglect  the  teeth 
and  nails.  Efforts  should  be  made  to  inculcate  fixed 
habits  of  tidiness  by  inducing  the  patient  to  sit  upon 
the  chamber  or  taking  him  to  the  closet  at  stated  times 
if  he  is  strong  enough  to  be  gotten  up  from  bed.  The 
condition  of  the  bowels  should  be  carefully  looked 
after  that  constipation  or  other  derangements  may  not 
ensue.  Heed  should  be  given  that  the  patient  urinates 
at  regular  intervals.  Patients  laboring  under  excite- 
ment fail  to  empty  the  bladder  from  inattention;  pa- 
tients suffering  from  depression,  because  of  apathy  and 
indifference.  Paretic  patients  often  have  distention  of 
the  bladder  because  of  lack  of  power  to  expel  its  con- 


206  MANAGEMENT   OF   CASES — NURSING. 

tents,  or  because  of  the  absence  of  the  impulse  to  uri- 
nate, arising  from  sensory  paralysis.  It  is  important 
to  call  to  the  attention  of  the  physician  any  suspicion 
of  failure  of  the  patient  to  empty  the  bladder,  that  the 
dismal  accident  of  rupture  may  not  occur.  The  details 
of  catheterization,  giving  of  enemata,  attention  to  bed- 
sores, and  care  of  the  feeble  pertain  to  ordinary  sick- 
nursing. 

In  nursing  the  insane  it  should  be  constantly  borne 
in  mind  that  symptoms  of  any  disease,  as,  for  instance, 
pneumonia,  may  be  masked  by  the  mental  condition, 
and  that  complaint  may  not  be  made  of  pain,  discom- 
fort, or  even  severe  distress. 

TEMPERATURE  TAKING. — The  rule  should  be  to  take 
temperature  elsewhere  than  in  the  mouth.  I  have 
known  a  patient  to  bite  off  and  swallow  a  portion  of 
the  thermometer.  The  thermometer  should  be  sur- 
gically clean. 

EXERCISE. — It  is  of  the  utmost  importance  that  one 
suffering  from  mental  disease,  whose  strength  will  per- 
mit, should  be  taken  out  of  doors  for  exercise  every 
day  in  pleasant  weather.  Great  caution  should  be  ob- 
served to  assure  one's  self  that  the  patient's  physical 
condition  will  admit  of  his  going.  He  should  not  be 
taken  for  exercise  to-day  because  of  a  general  direc- 
tion to  this  effect  yesterday,  but  the  advisability  of  the 
act  should  be  invariably  considered  before  a  step  is 
taken.  There  should  be  care  that  the  walk  is  not  too 
long ;  that  the  patient  is  not  fatigued  by  it ;  that  he  is 
not  taken  into  places  of  danger ;  that  he  is  not  exposed 
to  the  cold,  or  to  the  heat  of  the  sun  unduly ;  that  he 
is  suitably  clothed ;  that  he  is  not  permitted  to  sit  upon 
the  damp  ground  or  loiter  in  places  where  he  may  be 


MANAGEMENT    OF    CASES NURSING.  207 

seen  by  others  and  his  condition  made  the  subject  of 
remark.  In  maniacal  excitement,  unless  the  strength 
is  too  much  reduced  (and  in  a  decision  of  this  kind  the 
opinion  of  the  physician  should  be  taken),  walks  are 
frequently  well  borne  and  profitable.  The  restlessness 
of  mania  must  have  vent.  To  repress  it  too  much  is 
to  intensify  excitement  and  do  the  patient  harm.  In 
the  occupation  of  walking  out  of  doors  there  is  a  diver- 
sion of  the  nervous  energy  into  healthful  channels. 
The  sleep  and  the  appetite  are  better,  and  all  the  bodily 
functions  are  more  satisfactorily  performed  in  conse- 
quence of  it.  Fresh  air  in  abundance  is  introduced 
into  the  lungs ;  the  blood  is  more  rapidly  and  perfectly 
oxygenated — it  is  of  a  more  favorable  quality  to 
nourish  the  brain.  The  bodily  secretions  are  quick- 
ened. That  form  of  exercise  is  the  best  in  which  the 
largest  number  of  muscular  groups  can  be  utilized,  and, 
in  depression,  that  the  most  satisfactory  which  intro- 
duces a  variety  of  healthy  percepts  into  consciousness. 
This  is  true  for  obvious  reasons,  it  having  been  shown 
under  "Limitations  of  the  Will"  that  a  thought  can- 
not be  dismissed  by  mental  effort,  but  must  be  sup- 
planted by  another  in  order  that  it  may  be  removed. 
Patients  suffering  from  mental  depression  are  fre- 
quently averse  to  going  out  of  doors,  or  even  into  the 
society  of  their  fellow-patients.  In  overcoming  this 
disposition,  the  nurse  is  promoting  his  patient's  well- 
being  and  lessening  the  intensity  of  morbid  mental 
operations  by  presenting  healthful  subjects  for  con- 
templation. Pleasurable  emotions  stimulate  vital 
activity.  All  are  aware  of  the  depressing  effects  of 
trouble — bad  news,  mental  shock — how  they  take  away 
the  appetite  and  derange  the  bodily  functions.  The 


208  MANAGEMENT   OF    CASES — NURSING. 

contrary  is  true  of  pleasurable  emotions.  All  of  the 
vital  functions  are  stimulated  by  these  to  greater  activ- 
ity; hence  their  importance  as  aids  to  the  recovery  of 
the  insane. 

In  depression  with  hypochondriasis  there  is,  gener- 
ally speaking,  disinclination  to  take  exercise,  and  it  is 
important  that  this  disposition  should  be  met  and  the 
determination  of  the  patient  to  remain  indoors,  in  his 
room  or  in  bed,  be  thwarted.  Much  caution  should  be 
observed,  however,  that  undue  exercise  is  not  taken, 
and  the  patient's  complaints  and  protests  should  be 
duly  weighed.1 

EMPLOYMENT  and  DIVERSION  are  desirable  for  the 
same  reasons  that  exercise  is  desirable.  Through  them 
healthful  topics  of  thought  are  introduced  to  displace 
those  of  a  morbid  character:  the  muscular  action  is 
diverted  from  unhealthful  into  healthful  channels; 
voluntary  control  is  stimulated;  the  ability  to  fix  the 
attention  is  increased;  restlessness,  disorder,  and  de- 
structiveness  are  diminished;  sleep,  appetite,  and  the 
bodily  functions  are  improved.  The  furnishing  of  a 
congenial  diversion,  such  as  taking  a  patient  to  a  con- 
cert or  a  church  service,  often  supplies  an  effective 
motive  for  self-control  and  is  a  stepping-stone  to  his 
recovery. 

In  recent  mental  diseases  employment  is  of  service 


1 1  once  knew  a  hypochondriacal  patient  to  be  sent  out  of 
doors  for  a  walk  by  her  physician,  it  being  believed  by  him 
and  by  all  who  had  dealings  with  her  that  her  objections  to 
going  out  were  purely  mental,  and  that  there  was  no  physical 
condition  which  would  be  a  barrier  to  the  exertion.  On  the 
morning  in  question  she  had  gone  but  a  few  steps  when  she 
fell  dead  from  heart  failure. 


MANAGEMENT    OF    CASES NURSING.  209 

for  the  immediate  well-being  of  the  patient,  substitut- 
ing new  topics  of  thought  and  directing  the  energy 
along  useful  lines. 

In  arresting  the  tendency  to  dementia,  employment 
is  of  the  utmost  value.  In  settled  dementia  we  not 
only  find  employment  an  outlet  for  nervous  energy, 
which  is  apt  to  expend  itself  in  moving  restlessly  to 
and  fro,  in  picking  at  the  clothing,  and  in  degrading 
habits,  but  we  possess  in  it  a  means  of  re-education  of 
the  brain,  -of  opening  new  routes  of  nervous  travel, 
and  bringing  into  action  groups  of  nerve-cells  not 
formerly  in  commission.  As  my  experience  increases 
I  am  more  and  more  convinced  of  the  practicability  of 
employing  almost  all  patients,  no  matter  what  their 
mental  condition  may  be — save  those,  of  course,  en- 
feebled in  body  from  paralysis  or  other  cause — in  some 
line  of  work.  The  employment  may  be  simple,  but 
will  be  found  sufficient  to  contribute  materially  to  the 
welfare  of  the  patient  and  that  of  others. 

Knitting  is  an  employment  of  great  value.  Knowing 
my  interest  in  it,  a  patient  once  wrote  the  following 
acrostic : — 

Such  a  great  panacea  for  all  human  need, 

At  last  is  discovered  they  say; 

Let  me  tell  you  no  joke  is  intended,  indeed, 

Vive  la  science!  (of  knitting)  this  day. 

Away  with  such  nonsense  as  powders  and  pills, 

They  rather  increase  than  diminish  our  plight, 

If  all  I  have  heard  be  quite  true,  then  it  kills 

Oftentimes  to  be  dosing  from  morning  till  night 

Now  or  never  this  fact  must  be  truthfully  told, 

It  is  work  that  makes  all  life  complete  without  blight 
No  distinction,  no  rank,  no,  not  barrels  of  gold 

14 


210  MANAGEMENT    OF    CASES NURSING. 

Will  give  one  the  joy  that  one  neatly  knit  bag, 

Or  a  pair  of  golf  stockings  just  done  to  a  turn, 

Rosy  mittens,  bed  slippers,  a  handy  wash-rag, 

Knit,  my  friends,  by  the  sweat  of  your  brow.   You  shall  learn 

Contentment.     The  reason  is  evident  now. 

Why  the  Doctor's  accustomed  to  knitting  his  brow. 

By  introducing  variety  (not  too  much  variety,  but 
a  little  diversion  and  change)  into  the  daily  lives  of 
patients,  we  are  helping  mental  action,  substituting 
new  topics  of  thought,  and  widening  the  mental 
horizon.  Patients  should  be  induced  to  do  different 
things  or  the  same  thing  in  different  ways.  If  a 
morbid  tendency  leads  one  to  remain  in  a  certain  posi- 
tion for  hours  at  a  time  the  current  should  be  inter- 
rupted; something  new  presented  in  exchange  for  the 
old.  If  a  particular  seat  is  selected  in  obedience  to  a 
habit  of  dementia,  change  the  location  of  the  chair,  or 
furnish  another  surreptitiously.  If  the  patient  insists 
upon  sitting  in  his  room  unoccupied  and  absorbed  in 
morbid  thoughts,  induce  him  to  work,  break  up  in 
some  way  the  dry  routine,  and  force,  little  by  little, 
little  by  little  (not  too  rapidly,  lest  he  tire),  some 
healthful  concepts  into  his  consciousness.  The  use  of 
games  should  be  general  and  frequent,  and  in  patients 
who  have  no  natural  desire  for  amusements  a  taste 
should  be  cultivated.  Be  it  ever  so  simple  and  child- 
like, occupation  or  amusement  of  some  kind  intro- 
duced into  the  patient's  life  will  be  of  great  service  to 
him. 

In  the  progress  of  mental  disease  brain  waste  is 
rapid.  Restoration  and  repair  are  brought  about 
during  SLEEP.  It  is  consequently  important  that 
nothing  should  interfere  with  the  patient's  obtaining 


MANAGEMENT    OF    CASES NURSING.  211 

a  suitable  amount  of  rest.  Exercise  and  employment 
in  the  daytime  and  the  establishment  of  fixed  habits  of 
living  go  far  to  bring  this  desirable  state  of  things 
about.  Inability  to  sleep  frequently  depends  upon 
actual  starvation  of  the  nerve  centers.  Under  such 
conditions  the  taking  of  a  little  food  just  before  re- 
tiring— as  a  glass  of  hot  milk  or  a  cup  of  cocoa  or 
chocolate — may  be  all  that  is  necessary  to  induce  re- 
pose. A  warm  bath  or  cool  sponging  to  the  spine  will 
also  be  found  of  value  in  some  cases.  Where  medicine 
is  prescribed  for  the  purpose  of  producing  sleep  it 
should  be  administered  under  the  careful  directions  of 
the  physician;  should,  as  a  rule,  not  be  given  where 
circumstances  warrant  its  temporary  withdrawal;  and 
should  be  discontinued  as  soon  as  habits  of  sleep  are 
measurably  re-established.  In  this  matter,  as  well  as 
in  others  connected  with  the  management  of  such 
cases,  the  patient's  individuality  should  be  carefully 
studied.  The  reason  why  he  does  not  sleep  should  be 
discovered,  if  possible,  and  means  taken  to  meet  the 
indication.  One  persistently  wakeful  and  noisy  at 
night — this  from  sheer  timidity  when  sleeping  alone — 
may  be  quiet  and  calm  and  rest  well  in  a  dormitory 
with  others.  A  patient  whom  I  once  had  under  obser- 
vation, who  for  years  was  thought  to  require  a  hyp- 
notic at  night  because  of  noisy  demonstrations,  slept 
like  a  child  after  being  placed  in  a  covered  bed,  be- 
cause he  believed  that  while  there  his  enemies  could 
not  steal  his  sheep.  Another  patient,  suffering  from  a 
chronic  form  of  disease,  was  noisy  the  night  through 
until  afforded  one  day  the  opportunity  to  lie  down  for 
an  hour.  That  night  she  slept,  and  on  succeeding 
nights,  if  she  had  napped  in  the  daytime,  she  rested 


212  MANAGEMENT    OF    CASES NURSING. 

well.  Aching  teeth,  of  which  the  patient  may  not  com- 
plain, are  an  occasional  cause  of  sleeplessness. 

Prolonged  rest  in  bed  is  frequently  necessary. 
Certain  cases  of  manic-depressive  insanity  of  the  alter- 
nating type  are,  in  disturbed  periods,  quieter  and  more 
comfortable  if  permitted  to  remain  alone  in  bed  than 
if  up  and  about.  Here  exhaustion  of  the  brain  is  less, 
the  horizontal  position  affording  a  means  for  more 
perfect  nutrition  of  that  organ.  Fewer  percepts  are 
introduced  into  consciousness,  and  mental  confusion 
is  less.  In  ordinary  recurrent  cases  this  plan  would  be 
inadvisable,  but  in  those  exceptional  ones  attended  by 
much  confusion  and  a  high  grade  of  excitement  it  is 
frequently  of  great  service.  In  acute  exhaustive  con- 
ditions the  patient  should  be  kept  in  bed  to  prevent 
further  physical  decline,  and  should  be  nursed  as  one 
in  the  delirium  of  fever.  In  depressive  states  attended 
by  great  physical  prostration,  the  mental  operations 
are  often  surprisingly  improved  by  a  few  days  in  bed 
in  a  horizontal  posture — this  for  the  reason  already 
given. 

The  objections  to  rest  in  bed  are:  the  dangers  of 
suicide,  of  the  formation  of  habits  of  inactivity,  and 
of  the  development  of  untidiness.  These  objections 
may  be  met  by  watchfulness  and  attention. 

Bathing. — The  presence  in  the  room,  even  when  her 
assistance  is  not  actively  needed,  of  the  nurse,  is  neces- 
sary to  ward  off  the  danger  of  intentional  drowning, 
of  scalding,  or  of  accident.  During  the  prolonged 
bath,  pulse  count  should  be  made  at  frequent  intervals 
and  if  any  marked  acceleration  or  lowering  of  the  rate 
is  discovered  the  fact  should  be  at  once  reported  to 
the  physician  in  attendance.  Where  his  advice  is  not 


MANAGEMENT   OF   CASES — NURSING.  213 

available,  the  bath  should  be  immediately  suspended, 
the  patient  placed  in  bed  and  cooling  applications  made 
to  the  head  and  upper  part  'of  the  body. 

Correcting  Pernicious  Habits  and  Checking  Morbid 
Impulses. 

As  the  tendency  of  the  insane  person's  mind  is  to- 
ward neglect  in  personal  appearance,  disorder,  lack  of 
self-control,  contemplation  of  morbid  subjects,  and 
impulsive  acting,  the  energies  of  those  having  the  re- 
sponsibility of  his  care  should  be  directed  to  the  estab- 
lishment of  neatness, .  the  correcting  of  habits  of 
neglect,  the  repression  of  evil  or  pernicious  tendencies, 
the  substitution  of  natural  for  unnatural  thinking,  and 
the  restoration  of  habits  of  self-control.  This  is  symp- 
tomatic treatment. 

In  the  care  of  the  insane  punishment  should  never 
be  employed. 

Punishment  is  the  infliction  of  pain  for  a  crime  or 
fault.  The  insane  person,  having  lost  by  disease  his 
ability  to  feel,  to  think,  and  to  act  in  a  natural  manner, 
is  not  responsible  and  should  never  be  punished.  It  is 
appropriate,  in  my  judgment,  to  supply  certain  motives 
to  self-control ;  as,  for  instance,  withdrawal  of  tobacco 
from  those  untidy  in  its  use;  or  denying  those  who 
have  been  guilty  of  improprieties  the  privilege  of  at- 
tendance upon  assemblies.  These  disciplinary  meas- 
ures, though  possibly  regarded  by  the  patient  himself 
as  punishment,  cannot  justly  be  thus  considered.  They 
are  steps  taken  with  the  end  in  view  of  promoting  the 
patient's  self-respect  and  establishing  habits  of  neat- 
ness and  self-control.  The  withdrawal  of  food  or  any 


214  MANAGEMENT    OF    CASES NURSING. 

of  the  necessities  of  life,  as  a  correction  for  a  fault, 
could  never  be,  under  any  circumstances,  excusable, 
though,  on  the  contrary,  on  rare  occasions  the  furnish- 
ing of  a  reward — as  fruit,  candy,  or  a  delicacy — be- 
cause of  some  particularly  praiseworthy  and  com- 
mendable conduct,  may  be  wise.  Scolding  or  harsh 
and  ungentlemanly  or  unladylike  language  should 
never  be  indulged  in.  It  does  no  good  and  is  the  source 
of  no  end  of  disagreement  and  trouble.  One  is  never 
excusable  for  incivility;  and  any  tendency  in  this 
direction  which  the  nurse  is  conscious  of  in  himself  or 
which  he  sees  in  others — patients  or  employees — 
should  be  corrected  where  practicable. 

Employ  the  prefix  "Mr."  or  "Mrs."  invariably  in 
addressing  your  patient.  Make  requests;  do  not  com- 
mand. A  request  pleases ;  a  command  antagonizes. 
An  attitude  of  imperiousness  toward  the  patient  dimin- 
ishes his  regard  for  the  nurse,  and  if  the  "order"  is 
obeyed  it  is  at  the  cost  of  his  self-respect.  The  nurse 
should  be  equally  careful  not  to  be  patronizing.  To 
the  majority  of  patients  a  patronizing  air  is  highly 
offensive. 

In  the  government  of  patients,  a  firm,  judicious  posi- 
tion should  be  taken  and  maintained.  Be  sure  of  the 
right  and  propriety  of  the  course,  then  consistently 
pursue  it.  Let  the  judgment  be  made  up  calmly. 
Waste  no  time  in  arguing  or  in  reiterating  again  and 
again  what  will  be  done  in  case  compliance  with  a  re- 
quest is  not  forthcoming.  The  repeated  You  shall's, 
which  only  call  forth  the  /  shall  not's,  anger  both 
parties  and  are  unseemly.  After  calmly  and  dispas- 
sionately telling  your  patient  what  course  will  be  taken 
in  case  of  indulgence  in  some  particular  line  of  con- 


MANAGEMENT   OF   CASES — NURSING.  215 

duct,  carry  out  the  plan  without  further  talk  if  the 
conduct  is  repeated. 

"How  do  you  get  on  with  this  patient  so  well  nowa- 
days?" I  once  asked  a  nurse.  "I  guess  it  is  because 
I've  quit  having  the  last  word,"  she  replied. 

Avoid  too  much  talking;  heed  reasonable  requests; 
take  a  firm  and  judicious  position  and  maintain  it. 

The  ideal  nurse  is  calm,  unassuming,  serene,  and 
well  poised,  not  too  talkative,  but  responsive.  He 
loses  no  time  by  false  motions  and  does  not  require  to 
do  work  twice  over  because  of  failure  to  perform  it 
well  in  the  beginning.  He  does  not  make  the  mistake 
of  being  overzealous.  He  realizes  just  how  far  he 
may  be  suggestive  without  antagonizing  his  patient 
and  arousing  irritability  and  resistance. 

Some  of  the  best-meant  efforts  fail  from  overdoing. 
This  is  notably  true  of  those  which  are  attended  by  too 
much  talking.  Talk  often  tires.  In  conversation  with 
one  whose  mental  powers  are  weakened  by  disease, 
one  should  always  remember  the  danger  of  over- 
stimulation  producing  mental  fatigue  and  confusion. 

The  ideal  nurse  performs  his  duties  noiselessly, 
spends  no  time  in  getting  ready  to  do,  wastes  no  words 
about  what  he  is  planning,  but  quietly  and  determinedly 
acts  upon  his  best  judgment.  There  is  no  assumption 
of  arrogance  in  his  demeanor,  no  blow  and  bluster,  no 
fuss  and  feathers.  He  merely  displays  a  quiet  as- 
sertiveness  and  a  fixed  resolve,  the  effect  of  which 
latter  is  intensified  by  the  unostentatious,  unobtrusive 
manner  behind  it.  It  is  the  tactful,  the  discreet,  the 
judicious  man,  not  necessarily  the  one  of  great  physi- 
cal strength,  who  best  succeeds  in  the  management  of 
cases  of  mental  disease.  Great  physical  strength  is 


216  MANAGEMENT   OF   CASES — NURSING. 

desirable  only  if  there  is  present  with  it  that  gentleness 
in  its  exercise  which  one  of  well-disciplined  mind  dis- 
plays. There  is  danger  if  its  possessor  is  led  into  the 
error  of  relying  upon  it  to  the  neglect  of  those  means 
of  management  which  are  the  result  of  thought,  good 
judgment,  and  careful  study.  I  once  knew  a  nurse 
who  was  affectionately  dubbed  "Charles"  by  the 
gentleman  for  whose  wants  he  was  providing.  "How 
do  you  get  on  with  Charles?"  I  asked  the  patient,  one 
evening  after  having  during  the  day,  myself  unob- 
served, witnessed  the  relations  of  the  two  while  out 
walking,  noticed  the  self-contained  manner  of  the 
nurse  and  his  judicious  meeting  of  what  might  have 
proven  a  serious  episode.  "Very  well,"  was  the  gentle- 
man's reply ;  "very  well,  indeed.  He  has  his  own  way 
usually.  Charles  is  a  very  determined  man,  a  man  of 
very  few  words ;  but  when  he  says  come,  you  might  as 
well  come." 

One  should  be  determined,  but  invariably  polite.  In- 
sistence against  the  will  of  another  upon  a  course  of 
action  is  robbed  of  its  offensiveness  if  it  is  politely 
made.  One  should  not  say  "come"  unnecessarily  and 
should  be  very  careful  not  to  take  a  position  with  a 
patient  which  he  cannot  defend.  He  should  never 
threaten  something  which  he  could  not  do  with  proper 
regard  for  the  welfare  of  the  patient  and  the  institu- 
tion whose  reputation  he  has  in  his  keeping. 

When  necessary  to  say  "come,"  say  it  kindly.  "I 
would  if  I  were  you,"  is  an  expression  infinitely  less 
repellant  than  "you  must";  but  even  these  unpleasant 
words  may  be  deprived  of  offensiveness  by  a  gentle 
apologetic  manner  in  the  speaker.  Never  say  "you 
must"  unless  compelled  to.  If  what  you  ask  is  not  ac- 


MANAGEMENT    OF    CASES NURSING.  217 

corded  with,  do  not  repeat  the  request,  but  gently  and 
firmly  enforce  compliance  with  it. 

MANUAL  RESTRAINT,  when  necessary,  should  be  ap- 
plied with  the  least  possible  show  of  force,  and  never 
with  violence.  Forcible  control  may  be  necessary  to 
protect  the  patient  from  himself  and  to  protect  others 
from  him.  It  is  also  expedient  to  prevent  bad  habits 
and  improprieties,  to  correct  tendencies  to  restlessness 
and  excitement,  and  to  promote  self-control.  In  my 
experience,  force  judiciously  applied  and  used  as  a  last 
resort  is  rarely,  if  ever,  complained  of,  and  does  not 
give  rise  in  the  mind  of  the  patient  to  a  permanent 
grudge  or  grievance.  If,  however,  the  exhibition  of 
force  is  the  last  link  in  a  chain  of  unpleasant  circum- 
stances, for  which  the  nurse  is  to  blame,  its  employ- 
ment is  not  apt  to  be  forgiven.  To  illustrate :  A  com- 
mand to  do  some  particular  act  is  made,  and  is 
opposed  because  of  the  gruff  or  authoritative  manner 
behind  it;  a  dispute  arises;  attempts  to  coerce  are 
made  and  resisted;  both  nurse  and  patient  become 
angry,  and  in  the  end  the  patient  suffers  forcible  con- 
trol for  that  which  was  not  his  but  the  other's  fault. 
He  is  irritated  and  affronted,  and  justly  so.  He  has 
been  treated  badly. 

The  surroundings  and  person  of  the  patient  should 
be  spotlessly  clean.  An  effort  should  be  made,  by  the 
introduction  of  pictures,  books,  pretty  furnishings, 
musical  instruments,  and  games,  to  substitute  healthful 
for  morbid  topics  of  thought.  Seek  to  get  the  patient 
employed.  One  is  always  more  self-respecting  when 
useful. 

In  the  correction  of  certain  vicious  habits,  more  or 
less  frequent  among  those  whose  self-control  is  weak, 


218  MANAGEMENT    OF    CASES NURSING. 

active  manual  employment  in  the  daytime  and  watchful 
attention  at  night  are  the  only  agencies  upon  which 
safe  dependence  can  be  placed. 

The  suspiciousness  of  patients  is  best  met  by  frank- 
ness and  consistency,  or,  as  mentioned  under  "Adminis- 
tration of  Food,"  by  apparent  indifference. 

It  is  important  that  the  nurse  should  be  in  the  con- 
fidence of  the  patient;  hence  the  necessity  that  the 
latter's  early  impressions  of  his  surroundings  should 
be  favorable.  In  order  to  counteract  morbid  impulses, 
the  nurse  must  know  about  his  patient's  mental  opera- 
tions. Unless  in  his  confidence,  these  may  not  be 
revealed. 

Patients  are  suspicious  of  what  they  do  not  see.  It 
is  unquestionably  true  that  numberless  accusations  of 
abuse  are  based  upon  sounds  which  patients  hear 
issuing  from  rooms  with  closed  doors.  Hence,  so  far 
as  is  consistent1  with  modesty  and  propriety,  permit 
patients  to  see  how  others  are  cared  for. 

In  the  matter  of  delusions,  be  frank,  but  do  not  an- 
tagonize. If  a  patient  states  that  he  is  God,  it  is  en- 
tirely unnecessary  to  retort:  "No;  you  are  not."  If, 
however,  he  asks:  "Am  I  God?"  it  is  the  duty  of  the 
nurse  to  say :  "We  are  taught  that  the  Lord  has  never 
appeared  upon  earth  but  once,  and  then  in  the  person 
of  Christ,  many  years  ago."  In  this  or  in  some  other 
way  the  question  may  be  evaded,  or  the  nurse  may 
quietly  and  pleasantly  say :  "No,  sir ;  that  is  an  errone- 
ous belief."  Further  discussion  of  the  matter  is  un- 
necessary and  inadvisable.  This  applies  to  recent 
cases,  on  the  one  hand,  and,  on  the  other,  to  cases 


1  See  "Homicidal  Impulses,"  page  220. 


MANAGEMENT    OF    CASES NURSING.  219 

having  confirmed  delusions  of  long  standing.  In  the 
case  of  a  convalescent  patient,  however,  just  as  the 
mental  cloud  is  lifting,  timely,  judicious  conversation 
may  contribute  much  toward  assisting  him  to  correct 
morbid  judgments  and  control  diseased  impulses.  "He 
(pointing  to  the  nurse)  is  the  first  man  that  ever  told 
me  those  ideas  of  mine  were  not  right,"  said  a  patient. 
"At  home,  when  I  said  'I  have  the  light  here'  (opening 
his  coat),  they  told  me  it  shone  all  over  the  room.  He 
told  me  that  wasn't  so,  and  that  such  ideas  would  not 
be  believed  here." 

Homicidal  assaults  may  arise  in  consequence  of 
delusions,  or  impulsive  acts  not  intentionally  homicidal 
may  result  in  death.  The  delusions  which  lead  to 
homicide  are:  first,  those  of  persecution  or  of  con- 
spiracy; second,  those  of  impending  want  and  misfor- 
tune. The  only  effective  precaution  against  homicide 
is  vigilance.  It  is  the  duty  of  the  nurse,  in  cases  of 
quarrels  between  patients,  to  interfere.  This  may 
often  be  cleverly  done  by  requesting  of  one  his  assist- 
ance in  some  form  of  work  at  another  part  of  the 
room.  Knives,  scissors,  and  sharp  instruments  should 
always  be  kept  under  lock  and  key.  Brooms,  mops, 
dusters,  and  articles  of  this  kind  which  may  be  used 
as  weapons,  should  never  be  left  about,  but  locked  up 
immediately  after  using.  Chamber  utensils  should  be 
dealt  out  only  under  watchful  supervision.  Bath-tub 
keys,  which  may  be  used  like  a  brass  knuckle,  or  with 
which  hot  water  may  be  drawn,  should  never  be  per- 
mitted to  come  into  a  patient's  possession.  The  search- 
ing of  clothing,  bedding,  and  rooms  should  be  sys- 
tematically done — in  many  cases  daily,  in  the  majority 
of  cases  twice  a  week.  A  threatening  blow  may  some- 


220  MANAGEMENT   OF    CASES — NURSING. 

times  be  arrested  by  seizing  the  roll  of  the  coat  with 
both  hands,  and  quickly  drawing  the  coat  down  upon 
the  arms. 

Homicidal  impulses  may  exist  for  years  under  con- 
trol and  then  suddenly  develop;  hence  the  importance 
of  being  fully  informed  of  the  character  of  the  pa- 
tient's mental  operations,  and  being  ever  on  the  alert 
for  the  "unexpected,"  which  is  said  always  to  happen. 

The  impulsion  to  homicide  may  arise  in  strange 
ways.  A  patient  in  an  Eastern  asylum  who  required 
to  be  repeatedly  fed  artificially  and  always  strenuously 
objected  to  the  process,  was  struck  and  instantly  killed 
by  a  morose  and  reticent  patient  who  had  watched  the 
feeding  process  and  had  not  approved  of  it.  In  ac- 
counting for  his  conduct  the  homicidal  patient  said,  "I 
killed  him  so  that  he  would  not  have  to  be  fed  any 
more." 

Suicide  and  self-mutilation  may  be  prevented  by 
close  watching  and  attention  to  the  care  of  knives, 
sharp  instruments,  broken  glassware  and  crockery,  and 
other  articles  with  which  injury  may  be  inflicted. 
Suicide  by  precipitation  is  relatively  frequent;  hence, 
the  necessity  for  watchfulness  when  patients  are  out 
walking,  that  they  do  not  go  into  dangerous  localities ; 
that  they  have  no  opportunity  to  throw  themselves  be- 
fore automobiles  or  street  cars,  from  high  places  (as 
ladders  or  fire-escapes),  under  loaded  wagons,  or  into 
water.  Care  should  also  be  exercised  that  they  pick 
up  nothing  with  which  they  may  injure  themselves 
subsequently.  Indoors,  attention  should  be  given  to 
suicidal  patients  when  going  up  and  down  stairs,  and 
the  door  to  any  shaft  should  be  kept  closed  and  locked 
every  moment  when  the  nurse  is  not  standing  before 


MANAGEMENT   OF   CASES— NURSING.  221 

it.  Be  watchful  lest  suicidal  patients  throw  them- 
selves into  open  fireplaces,  scald  themselves,  drown 
themselves  in  bath-tubs,  hang  themselves  in  roller 
towels,  in  sheets  tied  at  the  window-guards,  or  in 
skeins  of  yarn  suspended  from  gas-fixtures.  A  pa- 
tient whom  I  once  knew  jumped  up  from  the  rocking- 
chair  in  which  she  had  been  quietly  sitting,  faced  the 
chair,  and  sprang  into  it,  only  to  throw  herself  back- 
ward upon  her  head.  She  died  almost  at  once.  Un- 
avoidable accidents  of  this  nature  will  sometimes  arise, 
notwithstanding  the  most  careful  watching ;  but  let  no 
patient  be  afforded  the  means  of  committing  suicide, 
homicide,  or  self-mutilation  through  the  carelessness 
of  the  nurse.  Do  not  make  the  mistake  of  believing 
that  because  a  patient  continually  talks  of  suicide  he 
will  not  carry  threats  into  execution.  Several  fatali- 
ties have  occurred  in  my  knowledge  among  patients  of 
this  class. 

Irritability. — This  is  frequently  an  expression  of 
physical  pain  of  which  the  patient  does  not  complain. 
Its  source  should  be  looked  for  in  sleeplessness,  head- 
ache, aching  teeth,  abdominal  pain,  constipation,  dis- 
tended bladder,  etc. 

MECHANICAL  RESTRAINT. — In  the  early  days  of  my 
hospital  experience  it  was  thought  necessary  to  use  me- 
chanical restraint  often.  Employment,  night-nursing, 
the  prolonged  bath,  and  personal  attention  have  done 
away  with  this  necessity,  until  now  in  a  well-ordered 
institution  resort  to  it  is  a  conspicuous  rarity.  It  may 
be  necessary  in  exceptional  cases,  but  should  never, 
except  in  a  grave  emergency,  be  applied  without  the 
previously  expressed  sanction  of  a  physician.  A  pa- 
tient in  restraint  should  be  visited  at  least  once  each 


222  MANAGEMENT   OF    CASES — NURSING. 

hour;  the  bedding  should  be  inspected,  and  necessary 
changes  made.  A  patient  in  restraint  is  helpless  and 
necessarily  more  or  less  uncomfortable  from  the  limi- 
tation of  muscular  movement.  Much  can  often  be 
done  to  mitigate  discomfort  by  friction  of  accessible 
portions  of  the  body,  by  cold  sponging  to  the  face  and 
neck,  or  by  the  application  of  water  warm  or  cold  to 
the  forehead.  Bear  in  mind  to  offer  drinking  water  at 
frequent  intervals  to  one  in  this  uncomfortable 
situation. 

SECLUSION. — The  isolation  of  a  patient  may  be  ex- 
pedient for  his  own  benefit,  or  for  the  good  of  others. 
When  done,  this  should  be  with  as  little  demonstration 
and  display  of  force  as  possible,  and  only  after  due 
warning  has  been  given.  The  course  may  be  neces- 
sary; first,  because  of  noisy  and  disorderly  conduct; 
second,  in  hysterical  patients  as  a  measure  of  good 
(lack  of  self-restraint  in  these  cases  always  being 
greater  when  the  patient  is  among  other  people)  ;  third, 
because  of  obscenity  or  indecency;  fourth,  to  with- 
draw the  nervous  subject  from  perturbing  influences 
and  thus  diminish  mental  confusion.1 

Patients  in  seclusion  should  be  visited  frequently. 
After  quietly  unlocking  the  door  (doors  should  always 
be  unlocked  quietly)  the  key  should  be  withdrawn  and 
placed  in  the  pocket  before  the  door  is  opened.  Both 

1  Epileptic  patients  during  confusional  states  are  frequently 
benefited  by  confinement  to  bed.  Noise  and  disorder  are 
lessened,  and,  fewer  percepts  coming  into  consciousness,  re- 
action, as  manifested  in  impulsive  assaults,  is  diminished. 
After  secluding  the  patient,  the  door  should  be  locked  quietly 
and  without  ostentation,  or  may  be  left  unlocked  if  it  is 
believed  that  the  patient  will  respect  the  injunction  to  remain 
within  the  room. 


MANAGEMENT    OF    CASES NURSING.  223 

hands  of  the  nurse  are  then  free.  The  practice  of  un- 
locking a  door  and  pushing  it  forward,  hand  on  key,  is 
extremely  reprehensible  and  dangerous.  In  entering 
the  room  of  one  who  has  broken  some  piece  of  furni- 
ture and  is  making  threatening  demonstration  with  a 
weapon  thus  secured,  an  effective  protection  is  a 
mattress  held  before  the  foremost  person.  By  means 
of  this  the  patient  may  be  crowded  back  and  disarmed. 

The  objections  to  seclusion  are :  the  danger  of  sui- 
cide-; the  danger  of  increasing  irritability;  the  danger 
of  untidiness.  A  suicidal  patient  should  never  be 
secluded  except  with  the  previously  expressed  consent 
of  the  physician,  and,  if  apart  from  others,  should  be 
carefully  looked  after.  Seclusion  sometimes  increases 
irritability,  ill  feeling,  and  waywardness.  When  this 
occurs  harm  results  and  the  measure  is  inexpedient. 

The  disposition  to  burn  and  the  tendency  to  steal  are 
observed  in  different  forms  of  insanity.  The  fact  that 
these  symptoms  are  conspicuously  manifested  in  some 
cases  has  led  to  their  being  improperly  dignified  by 
special  names  for  disease:  as  pyromania  and  klepto- 
mania. The  tendency  to  burn  is  most  frequently  ob- 
served in  connection  with  chronic  delusional  insane 
conditions  and  in  imbecility;  the  tendency  to  steal  in 
the  early  stages  of  paretic  dementia,  property  being 
appropriated  by  the  patient  under  the  delusion  that  it 
is  his  own.  Patients  who  are  demented  are  apt  to 
secrete  articles  of  no  value,  or  little  value,  and  unless 
carefully  observed  get  together  accumulations  of  rub- 
bish and  useless  trumpery. 

Searching  the  clothing,  the  bedding,  and  possessions 
of  patients  for  matches  and  other  articles  collected, 
and  extreme  watchfulness  to  prevent  things  of  this 


224  MANAGEMENT    OF    CASES NURSING. 

nature  falling  into  the  patient's  hands,  are  safeguards 
against  accidents  from  these  sources. 

DESTRUCTIVENESS. — Certain  patients  are  as  suscepti- 
ble as  little  children  to  rewards,  and  right  doing  may 
be  stimulated  by  promises  of  such.  Where  the  habit 
of  destructiveness,  particularly  destructiveness  to 
clothing,  is  thoroughly  formed,  however,  it  is  difficult 
to  correct  it  and  the  ability  of  the  patient  to  restrain 
the  impulse  to  tear  soon  wears  out.  One  patient  whom 
I  knew  was  offered  by  the  superintendent  a  penny  a 
day  for  every  day  that  he  kept  a  new  suit  of  clothes 
in  good  order.  He  received  his  penny  each  day  from 
Monday  until  Saturday  inclusive.  On  Sunday  night 
he  was  found  in  a  state  of  great  dilapidation.  "Oh, 
Frank,  I  am  very  sorry  to  see  you  in  such  a  plight," 
said  the  superintendent.  "You  have  not  earned  your 
penny  to-day."  "Well,"  was  the  stuttering  reply,  "I'll 
be  d— d— d—  if  I'll  work  S-S-S-undays." 

ESCAPES. — In  these  days  of  open-door  halls,  employ- 
ment out  of  doors,  and  the  giving  of  larger  and  larger 
liberties  to  patients,  escapes  will  unfortunately  occur. 
They  should  never  be  chargeable  to  lack  of  vigilance 
or  to  disobedience  of  rules  or  regulations.  Escapes,  as 
other  accidents,  only  too  frequently  take  place  as  the 
result  of  neglect  of  printed  rules.  Remember  that  the 
escape  of  a  patient  may  mean  a  homicide,  an  act  of 
arson,  a  suicide,  or  some  ghastly  episode,  account- 
ability for  which  would  be  deeply  regretted. 

Never,  under  any  circumstances,  talk  of  the  condi- 
tion of  any  patient  to  any  person  not  entitled  to  re- 
ceive information  about  him. 

It  is  as  true  of  the  nurse  as  of  the  physician  that 
highest  efficiency  is  not  reached  without  the  develop- 


MANAGEMENT    OF    CASES NURSING.  225 

ment  of  the  spiritual  side  of  the  nursing  art.  It  is  even 
more  true  in  fact  as  the  nurse's  contact  with  the  pa- 
tient is  infinitely  closer  and  opportunity  for  helpful 
suggestion  is  correspondingly  more  frequent.  It  is 
important  that  the  nurse  should  be  early  imbued  with 
the  idea  that  medicine-giving  is  not  the  alpha  and 
omega  of  treatment,  even  when  it  is  a  question  of  the 
relief  of  pain,  which  may  be  so  readily  quieted  by  re- 
sort to  what  a  patient  once  stigmatized  as  the  "hypo- 
devil."  It  is  feared  that  many  nurses  with  carte 
blanche  to  administer  them  too  early  turn  to  sedatives 
and  hypnotics  and  give  them  in  too  liberal  quantities. 
Strong  suggestion  suffices  in  many  cases.  It  was  once 
remarked  by  a  surgeon  in  my  hearing  that  a  certain 
nurse  trained  in  a  sanitarium  making  little  use  of 
drugs  was  the  most  efficient  he  had  found  in  the  care 
of  surgical  cases.  She  was  resourceful,  had  ways  of 
meeting  the  little  plaints  of  patients — resting  them  by 
change  of  position,  rubbing  them  or  readjusting  bed- 
clothing — that  were  frequently  disregarded  by  the 
surgical  nurse  of  general  hospital  training. 

It  is,  perhaps,  not  too  strong  a  statement  that  the 
emotions  have  a  weighty  influence  in  the  repair  of 
tissues.  It  is  a  fact  of  the  commonest  experience  that 
emotional  depression  is  a  constant  accompaniment  of 
operations  upon  those  organs  most  liberally  supplied 
by  the  sympathetic  nervous  system.  That  healing  of 
such  parts  after  surgery  may  go  on  satisfactorily,  it  is 
the  custom  to  divert  the  patient  so  far  as  possible  from 
contemplation  of  the  local  symptoms  by  taking  him 
from  bed  and  supplying  entertainment.  That  this  may 
be  overdone  goes  without  saying,  but  the  adoption  of 
the  method  by  surgeons  indicates  how  important  to 

15 


226  MANAGEMENT   OF    CASES — NURSING. 

the  healing  processes  a  cheerful  play  of  the  emotions 
is  regarded. 

From  among  nurses  caring  for  the  insane  whom  I 
have  known  there  might  be  constituted  a  large  army 
of  men  and  women,  than  whom  none  could  be  more 
loyal,  true,  devoted,  and  self-sacrificing.  If  their 
merits  have  sometimes  seemed  to  fail  of  appreciation 
they  are  at  least  entitled  to  the  comfort  that  springs 
from  the  reflection : — 

"Charity  ever  finds  in  the  act  reward." 


INDEX. 


Ability,  inherited,  acquired, 

32 

Aboulia,  157 
Acute   confusional  insanity, 

76 
Administration  of  food,  200 

of  medicine,  204 
Adolescence,  66 
Agraphia,  27 
Aims   in   treatment,    199 
Alcohol  rub,  77 
Alcoholic    delirium,   82 

delusional  insanity,  87 

epilepsy,  92 

intoxication,  82 

paranoia,  91 

pseudo-paresis,  88 
Alcoholism,  chronic,  87 
Alternating    type,    manic-de- 
pressive insanity,  69,  142 
Amoeba,  2 
Amusements,  208 
Anesthesia,  120 
Animal  kingdom,  22 
Anxiety  neuroses,  162 
Aphasia,  26 
Apoplectiform   seizures,    13, 

119,  131 
Applications,  hot  and  cold, 

77,  84,  190 
Apraxia,  27 
Arachnoid,  3 

Argyll-Robertson  pupil,  122 
Arson,  223 


Art  among  insane,  59 
Assaults,   homicidal,  219 
Association  of  concepts,  45 

paths,  11 
Ataxia,  27 
Atrophy,  79 

Attention,  personal,  205 
Attitude     toward     patients, 

214 

Autotoxis,  177 
Axone,  10 

Bath,  prolonged,   190 
Bathing,  general  directions, 

212 
Bed-sores,  120 

treatment,    174,    185,   212 
Bladder,     rupture     of,     115, 

120,  151,  190,  206 
Blood-pressure,  150 
Bones,  fragility  of,  120 
Brain,  5,  7,  8 

concussion,  6 

convolutions,  5,  6 

cortex,  5 

development  of,  9 

disease,  organic,  130 

disturbance    of    structure, 
6 

divisions  of,  3,  9 

injury  to,  6 

lobes  of,  8 

localization,  24 

membranes  of,  3 

(227) 


228 


INDEX. 


Brain,  organ  of  mind,  7 
Burning,  223 

Calisthenics,  196 
Care  of  nails,  205 

of  teeth,  204 

sanitarium,    74,   80,   84,   95, 

164,  186,  196 
Catheterization,  189 
Causes  of  insanity,  62 
constitutional,  65 
direct  physical,  64 
emotional,  64 
indirect  physical,   64 
involutional,  65 
Central  nervous  system,  4 
Cerebellum,  3 
Cerebral  localization,  24 
Cerebrum,  3,  5,  7 
Change  of  life,  66 
Chloral  habit,  181 
Choking,   120 
Chronic   alcoholism,-  87 

nervous  exhaustion,  78 
Classification,  studies  in,  68 
Cleanliness,  217 
Climacteric  period,  66 
Clothing,  205,  223 
Cocaine  habit,  92,  98 
Cold  applications,  85 

shower,  115 

spray,  81 

Collapse  delirium,  74 
Comparison  of  concepts,  23 
Complex,  114,  162 

in   dementia  prsecox,   114 

symbolism,  60 
Concealment,  43 


Concept,   19 
association,  45 

Concepts,   comparison   of,   23 

Concussion  of  brain,  6 

Confidence   of  patients,  224 

Confusional  insanity,  76 

Consciousness,   4,    16 
in  animals,  4 

Constipation,   122,   137,   145, 
176,  177 

Constitutional  causes,  65 

Contractures,  79,  130 

Convalescence,  196 

Conversation  with  patients, 
84 

Convolutions,  5 

Convulsions,  71,  92,  130,  131, 
151 

Cool    sponging,    77,    84 

Corpus  callosum,  12 

Correcting   pernicious    hab- 
its, 213 

Cortex  of  brain,  5 

Cranks,  168 

Cretinism,  99 

Crisis,  gastric,  116 

Custodial  care,  196 

Cystitis,  124 

Dangerous  impulses,  98,  103 

tendencies,  152 
Defect  of  development,  6 
Definition  of  insanity,  62 
Delirium,  alcoholic,  82 

and  fracture,  83 

collapse,  74 

narcotic,  82 

of  fever,  70 

of  infection,  71 


INDEX. 


229 


Delirium  of  pneumonia,  71 
of  typhoid,  71 
tremens,  82 
Delusions,   18,  40,   110,   117, 

132,  138,  167,  218 
visceral,  148 

Delusional     insanity,     alco- 
holic, 87 
Dementia,    employment    in, 

209 

habits  of,  210 
organic,  130 
paralytica,   116 
paretic,    116 
prsecox,  100 

complex  in,  114 
hebephrenic,    102 
katatonic,  108 
paranoid,  109 
symbolism  in,  57 
with  paralysis,  130 
Depression,  management  of, 

187 

Destructiveness,  224 
Development  of  mind,  13 
Differential    diagnosis,    173, 

187 

states  of  depression,   187 
states  of  excitement,  173 
Dipsomania,  86 
Direct  physical  causes,  64 
Distention  of  bladder,  115 
Disturbance   of   emotion,  6, 

45 

higher  reflexes,  45 
ideation,   6,   44 
intellection,  6 
judgment,  44 
memory,  44,  149 


Disturbance,    perception,     18, 
37,  38 

reasoning,  43 

sensation,  18,  73 

volition,  45 
Diversion,  208 
Division  of  animal  kingdom, 
22 

of  brain,  3 

Drugs,    depressing,    181,    184 
Dual  personality,  160 
Dura  mater,  3 

Education  of  animals,  4 

blind,  24 

child,  33,  34,  35 

deaf,  24 

emotions,  31 

volition,  35 

will,  35 
Ego,  17 
Egotism,  43 
Electric  breeze,  141 
Emotion   and   muscular  ex- 
pression, 30 

and  organic  functions,  29 
Emotional  causes,  64 
Emotions,  6,  28,  45 

morbid,  45 

Employment,  146,  208 
Encephalon,  3 
Enemata,    73,    81,    84,    115, 

135,  141,  189 
Epilepsy,  71,  92,  151 

alcoholic,  92 
Epileptic  insanity,  151 
Epileptiform    seizures,    119, 

124,  130,  131 
Eroticism,    103,   119,   155 


230 


INDEX. 


Erraticism,   101 

Erysipelas,  72 

Escapes,  224 

Etiology,  63 

Evasion,  43 

Evolutional  causes,  65 

Excitement,       management 

of,  174 

Exercise,  146,  206 
Exhaustion,    chronic    nerv- 
ous, 78 
psychoses,  74 

Faculties  of  mind,  12 
Febrile  delirium,  70 
Feeding,  200 

by  tube,   193,  203 

mechanical,  193,  203 

rectal,  73,  85,  97 
Feeling  (emotion),  28 
Fever,  delirium,  70 
Flight,  161 

of  ideas,  45 

Folie  circulaire,  69,  142 
Food,  administration  of,  200 

refusal  of,  201 
Forms   of  insanity,  67 
Fractures,  120,  15 1 
Fragility  of  bones,  120 
Freud,  57,  114,  155 
Freud's    views    of   hysteria, 

155 

Fugues,  161 

Functions   of  brain    (locali- 
zation), 25 

Ganglion,  4 
Gastric  crises,  116 
General   considerations,   37 
management,  medical,  172 


General    management,    nurs- 
ing, 199 
paralysis,  juvenile,  129 

of  the  insane,  116 
paresis,  116 
Gray  matter,  5,  7 
Groups  in  classification,  67, 
68 

Habit,  alcohol,  82 

drug,  92,  98 

vicious,  217 
Habits,  formation  of,  32 

of  dementia,  213 

of  destructiveness,  224 

of  inactivity,  210 

vicious,  65,  217 
Hallucinations,    37,    38,    39, 
107 

in  deaf  and  blind,  39 
Handwriting,  121 
"Harmless"  insane,  167 
Hearing,   13,  26 

center,   26 
Heart  tonics,  188 
Hebephrenic   form,    demen- 
tia prsecox,  102 
Hematoma  auris,  122 
Heredity,  65 
Higher  reflexes,  32 
disturbance  of,  45 
reflex  acts,  36 
volition,  35 
Homesickness,    197 
Homicidal  assaults,  168,  219 

impulses,  220 
Hospital  care,  74,  80,  84,  95, 

164,  186,  196 
Hydrotherapy,  81,  91,  97,  190 


INDEX. 


231 


Hyperthyroidism,  99 
Hypnotics,  86,  182 
Hypochondriasis,   78,  208 
Hypodermics,  77,  85,  95,  98, 

184 

Hypothyroidism,  99 
Hysteria,  155 

symbolism  in,  57 
Hysterical  insanity,  152 

dual  personality  in,  160 

obsessions  in,  58 
Hystero-maniacal  states,  156 

Ice  cap,  84,  98,  135 
Ideal  nurse,  199,  224 
Ideation,  6,  19,  44 

disturbance  of,  44 

impaired,  44 
Idiocy,  6,  165 
Illusions,  37 
Imbecility,  6,  165 
Impulses,   homicidal,   220 
Inattentiveness,  45 
Incivility,  214 
Incoherency,  45 
Indirect  physical  causes,  64 
Inequality  of  pupils,  80,  117 
Infection  delirium,  71 

psychoses,  70 
Inherited  powers,  32 

traits,  33 
Inhibition,  35 
Inhibitory  acts,  36 
Insane  ear,  122 

writings    of,    47,    59,    104, 
105,   106,    107,    112,    113, 
114,  121,  144,  145,  209 
Insanity,  acute  confusional, 
76 


Insanity,  alcoholic  delusional, 
87 

causes   of,  63 

classification  of,  68 

definition,  62 

epileptic,  151 

exhaustion    psychoses,    74 

forms  of,  67 

from  syphilis,  131 

hysterical,   152 

infection    psychoses,    70 

involutional,  147 

manic-depressive,'  132 

medical    management    of, 
172 

postfebrile,  73 

presenile,  147 

surgery  in,  192 

thyreogenous,  99 
Insight,  49 
Insomnia,   79,   81,    139,   146, 

182 

Instinct,  4 
Institutional  care,  74,  80,  84, 

95,  164,  186,  196 
Intoxication,    alcoholic,   82 

psychoses,  82 
Involutional  insanity,  147 
Irregularity  of  pupils,  122 
Irritability,  221 

Judgment,  2,  6,  23 

disturbance  of,  40 
Juvenile  paresis,  129 

Katatonic     form     dementia 

praecox,  108 

Kidney  displacements,   193 
"Kleptomania,"  223 
Knitting,  209 


232 


INDEX. 


Language,  zone  of,  27 

Lead  poisoning,  82 

Letters  of  insane,  47,  59, 
104,  105,  106,  107,  112, 
113,  114,  121,  144,  145, 
209 

Life,  definition  of,  1 

Limitation  of  volition,  37 
will,  37 

Litigiousness,  169 

Localization  of  brain  func- 
tion, 24 

Lumbar  puncture,  80,  126 

Management     of     insanity, 

medical,   172 
nursing,   199 

Manic-depressive  insanity,  132 
alternating  type,   142 
depressed  phase,  136 
excited  phase,  132 
Manslaughter,  35,  153 
Manual  restraint,  217 
Massage,  81,  115 
Mechanical  feeding,  193,  203 

restraint,  221 
Medical  examination,  43,  49, 

170,   173 

examiners,  43,  49,  170,  173 
treatment,   172 
Medicine,  administration  of, 

204 

Medulla  oblongata,  3 
Membranes  of  brain,  3 
Memory,  16,  19 
disturbance  of,  44,  149 
organic,   17 
Meningitis,  153 
Metasyphilis,   126 


Mind  and  brain,  5 

development  of,  12 

faculties  of,  12 
"Moral  insanity,".  143 
Morbid  impulses,  213 
Morphine  habit,  92 
Murder,  36 
Muscular  atrophy,  79 

inco-ordination,  45 

movements    in    emotional 
states,  31 

sense,  13,  39 

Nails,  care  of,  205 
Narcotic  delirium,  82 
Negativism,  48,   108,   109 
Nervous  exhaustion,  78 

force,  7 

system,    description,    4 
Neurasthenia,    78 

and  paretic  dementia,  123 

travel  in,  80,  196 
Neuritis,  73 
Neurone,  9,  10 
Neuropathic      organization, 

65,   100 

Neuroses,    anxiety,    162 
Nurse,  qualifications  of,  199, 

224 
Nursing,  205 

care  of  insane,  199 

Obsessions,  58 

hysteric   state,  57 

hysteroidal    state,    57 

of  words,  108 

paranoid  state,  57 

states  of,  156 
Opium  habit,  92 


INDEX. 


233 


Organic   brain    disease,    130 

dementia,  17 

memory,  17 
Othematoma,  122,  194 

Paralysis,     dementia     with, 

130 

of  bladder,  115,   120,   151, 
190,  206 

Paralytic  (paretic)  demen- 
tia, 116 

Paranoia,  165 
alcoholic,  91 

Paranoid  form  of  dementia 

prsecox,  109 
states,  symbolism  in,  57 

Parasyphilis,    125 

Paresis,  general,   116 
juvenile,  129 

Paretic  dementia,  116 
and  neurasthenia,  123 
differential        diagnosis, 
89,    123 

Pathology  of  insanity,  67 

Percept  grouping,   19 

Perception,  definition  of,  14 
impaired,  18,  37,  38 

Pernicious  habits,  213 

Personal  attention,  205 

Personality,  17 
dual,  160 

Petrolatum,  179,  189 

Phenomena  accompanying 
emotional  states,  6,  28, 
29,  30,  45,  64 

Pia  mater,  3 

Pinhole  pupil,   117 

Poisoning,  lead,  82 

Politeness,  214 

Pons  variolii,  3 


Postfebrile    conditions,   72 

insanity,  73 
Presenile  insanity,  147 
Pressure  of  activity,  48 
Private  care,  175 
Prolonged  bath,  77,  185,  190 

rest  in  bed,   174,  185,  212 
Pseudo-paresis,       alcoholic, 

88 

Psychoanalysis,  191 
Psychology,  1 
Psychoses,  exhaustion,  74 

infection,  70 

intoxication,  82 

postfebrile,  73 
Psychotherapy,  191 
Pubescence,  65 
Puncture,  lumbar,  80,  126 
Punishment,  213 
Pupil,  Argyll-Robertson,  122 

contracted,  122 

immobile,  117 

irregular,  122 

pinhole,  117 

unequal,  117,  122 
"Pyromania,"  223 

Qualifications  of  nurses,  199, 
224 

Reasoning,  20 

disturbance  of,  43 
Recollection,  19 
Rectal  feeding,  73,  85,  97 
Reflex  action,  32,  33 

acts,  36 

Reflexes,  disturbance  of,  45 
Refusal  of  food,  139,  142,  201 
Relation  of  emotion  to  mus- 
cular expression,  30 

mind  and  brain,  5,  7,  8 


234 


INDEX. 


Rest  in  bed,  174,  185,  212 

sheet,  78 
Restraint,  78 

manual  21/ 

mechanical,  221 
Retardation,  48 
Rewards,  214 
Rupture  of  bladder,  115,  120, 

151,  190,  206 
Russian  bath,  91,  115,  141 

Salt  glow,  115,  141,  188 

solution,  73 

Salvarsanized  serum,  129 
Sanitarium    care,    74,   80,   84, 

95,  164,  186,  196 
Scolding,  214 

Searching  clothing  and  bed- 
ding, 223 
Seclusion,  222 
Sedatives,  183,  184 
Seeing,  13 

Seizures,  apoplectiform,   13, 
119,  131 

epileptiform,  119,  124,  130, 

131 
Self-injury,  98,  103,  138 

-mutilation,  124,  220 
Senile  insanity,  147 

period,  66 
Sensation,   definition   of,   13 

impaired  in  disease,  18,  37 

modified  in  disease,  18 
Senses,  13 
Simple  neuritis,  73 
Sleep,  210 
Small-pox,  72 
Smelling,   13 

center,  26 


Special  senses,  13 

Spinal  cord,  4 

Static  breeze,  81 

Status  epilepticus,  151 

Stealing,  223 

Steam  bath,  91,  115,  141 

Stereotypy,  45,  47 

Suggestion,  191 

Suicide,  122,  138,  153,  220 

Surgery  in  insanity,  162,  192 

Suspiciousness,  218 

Swift-Ellis  treatment,  129    • 

Symbolism       in       dementia 

praecox,  57 
in  hysteria,  57 
in  paranoid  states,  57 
in  sanity  and  in  insanity, 
51 

Sympathetic  system,  4,  29, 
80 

Syphilis,  31,  116,  129,  131 

Syphilitic  insanity,  31 

Taking  temperature,  206 

Taste  center,  26 

Tasting,  13 

Teeth,  care  of,  204 

Temperature  taking,  206 

Tendon  reflexes  in  neuras- 
thenia, 79 

Thinking,  12 

Thyroid  gland  disturbance, 
99 

Touch,  13 

Travel  in  neurasthenia,  80, 
196 

Verbigeration,  45 
Vicious  habits,  65,  217 


INDEX. 


235 


Visceral  delusions,  148 
Vision,  13 
Visual  center,  26 
Volition,  32 

disturbance  of,  45 

education  of,  35 

higher,  35 

limitations  of,  37 

Vomiting,  153 


Wassermann  reaction,  80,90, 

125,  129,  132 
White  matter,  5 
Will,  32 

limitations  of,  37 
Witchcraft,  41 
Word  obsessions,  58,  60 
Writings  of  insane,  144 

Zone  of  language,  27 


Other  Publications  of  F.   A.  Davis   Company,  Philadelphia,  Pa. 
The    Leading    American    Work    on    the    Eye 

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A  PRACTICAL  TREATISE  ON  THE  ANATOMY,  PHYSI- 
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By   JAMES    MOORES  BALL,    M.D. 

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especially  of  students  and  general  practitioners   for  a  single 
volume  textbook  in  moderate  compass  at  small  cost. 


Other  Publications  of  F.   A.  Davis   Company,  Philadelphia,  Pa. 


Diseases  of  the  Ear,  Nose  andThroat 

By  WENDELL  C."  PHILLIPS,  M.D. 

Professor  of  Otology  in  the  New  York  Post-Graduate  Medical  School 

and  Hospital;  Surgeon  to  the  Manhattan  Eye,  Ear, 

and  Throat  Hospital,  New  York,  etc. 

Third  Revised  Edition.    Handsomely  Illustrated  with  nearly  600  Half- 
tone   and    Line    Engravings,    nearly    all    from    Original    Drawings 
and    Photographs,    including   33    Full-page    Plates.      Some    in 
Colors.      Royal    Octavo.     860   pages.      Cloth,    $6.00,    net; 
Half-morocco,  $7.50,  net.     Sold  only  by  Subscription. 

IT  is  pre-eminently  adapted  to  the  general  practitioner's 
daily  needs,  showing  him  in  text  and  picture  WHAT  the 

actual  conditions  are,  and  HOW  to  most  successfully  reach 
the  ends  sought  in  the  treatment  of  those  conditions.  A  sec- 
tion devoted  to  the  consideration  of  the  influence  of  general 
diseases  and  conditions  in  relation  to  the  ear,  nose,  and  throat 
has  permitted  the  grouping  of  a  variety  of  affections  (about 
37)  exhibiting  symptoms  or  lesions  referable  to  these  organs. 
This  section  appeals  especially  to  the  general  practitioner,  and 
is  valuable  for  reference. 

For  the  undergraduate  student  a  more  satisfactory  text- 
book cannot  be  found.  Its  simplicity  and  convenience  of 
arrangement,  the  great  number  of  original  illustrations  that 
really  teach,  make  it  particularly  well  adapted  to  the  last 
year's  work  in  college. 


Colorvision  and  Colorblindness 

A  PRACTICAL  MANUAL  FOR  PHYSICIANS,  OCULISTS, 
OPTICIANS,  AND  RAILROAD.  SURGEONS. 

By   J.   ELLIS    JENNINGS,  M.D. 

St.  Louis,  Missouri. 

Formerly  Clinical  Assistant  Royal  London  Ophthalmic 
Hospital  (Moor fields) ,  etc.,  etc. 

Crown  Octavo.    132  pages.    27  Text  Engravings  and  1 
Colored  Plate.     Cloth,  $1.00,  net. 


Other  Publications  of  F.  A.    Davis   Company,   Philadelphia,  Pa. 

Treatise  on  the  Motor  Apparatus 
of  the  Eyes 

INCLUDING  ANOMALIES  OF  THE  OCULAR  ADJUSTMENTS 

AND    THEIR   TREATMENT,    WITH    THE    ANATOMY 

AND    PHYSIOLOGY   OF   THE   MUSCLES   AND 

THEIR  ACCESSORIES. 

By  GEORGE  T.  STEVENS,  M.D.,  Ph.D. 

Of  New  York. 

Thoroughly  Illustrated  with  many  Original  Engravings,  some  in  Colors. 
Royal  Octavo.     Over  500  pages.     Extra  Cloth,  4.50,  net. 

/T  is\  profusely  and  elegantly  illustrated  in   colors  and  in 
•    black  and  white }  mostly  from  the  author's  own  drawings 
and   therefore  nearly   all   original.     The   illustrations   in 
Comparative  Anatomy  are  of  especial  interest. 

This  book  will  be  found  a  necessity  to  the  oculist  and  the 
neurologist,  while  to  physicians  in  all  branches  of  practice,  to 
physiologists  and  psychologists,  it  will  prove  a  work  of  the 
greatest  value  and  interest., 

Eye,  Ear,  Nose  and  Throat  Nursing 

By  A.  EDWARD  DAVIS,  A.M.,  M  D. 

Professor  of  the  Eye  in  the  N.  Y.  Post-Graduate 

Medical  School  and  Hospital, 

AND 

BEAMAN  DOUGLASS,  M.D. 

Professor  of  the  Nose  and  Throat  in  the  N.  Y.  Post-Graduate 
Medical  School  and  Hospital 

32  Engravings.     328  pages.     12mo.     Cloth,  $1.25,  net. 

EXTRA  stress  is  laid  on  Technique,  and  the  little  things 
which  count  so  much  for  success  or  failure  in  nursing 
are  given  their  due  attention.     The  chapters  on  Thera- 
peutics,  Antiseptics,   Emergencies,   and   on  the  after-care   of 
operations  will  prove  of  the  greatest  assistance  to  the  general 
practitioner  who  is  often   left  to  take  care  of  a  case  after 
operation  by  a  specialist.     Almost  as  often  as  he  is  doubtful 
as  to  just  what  to  do.    This  book  helps  him  out  of  his  troubles 
and  meets  an  urgent  need  in  this  respect,  and  in  many  other 
ways. 


Other  Publications  of  F.   A.  Davis   Company,  Philadelphia,  Pa. 

Health  and  Medical*  Inspection  of 
School  Children 

By   WALTER    S.    CORNELL,    M.D. 

Director  of  Medical  Inspection  of  Public  Schools,  Philadelphia;  Lec- 
turer on  Child  Hygiene,  tUniversity  of  Pennsylvania;  Director 
of  Division    of  Medical  Research,  New  Jersey   Training 
School  for  the  Feeble-minded,  Vineland,  N.  J.}  etc. 

Illustrated  with  200  Engravings,  mostly  original.     Crown  Octavo. 
614  pages.     Extra  Cloth,  $3.00,  net. 

DESIGNED  to  meet  the  growing  demand  of  teachers  and 
educators  generally  for  instruction  in  School  Hygiene 
and  the  diseases  and  defects  of  children  of  school  age. 
Physicians  will  find  it  invaluable  because  of  the  clear,  con- 
cise explanations  in  the  chapters  devoted  to  the  errors  of  re- 
fraction, the  influence  of  nasal  obstruction  on  the   develop- 
ment  of   the   dental   arches,   nervous    disorders,    and   mental 
defect. 

Sixth    Large    Edition 

Essentials  of  Laboratory  Diagnosis 

CONTAINING  THE  LATEST  PRACTICAL  METHODS  DE- 
SIGNED FOR  STUDENTS  AND  PRACTITIONERS. 

By  FRANCIS  ASHLEY  PAUGHT,  M.D. 

Director  of  the  Laboratory  of  the  Department  of  Clinical  Medicine, 

and  Assistant  to  the  Professor  of  Clinical  Medicine,  Medico- 

Chirurgical  College,  etc.,  Philadelphia,  Pa. 

Fully  Illustrated.    Ten  Full-page  Plates,  some  in  Colors  and  Numerous 
Engravings  in  the  Text.     Crown  Octavo.    450  pages.    Flexible 
Cloth.      Rounded    Corners.      $3.00,    net. 

SIXTH,  REWRITTEN,  REVISED  AND  ENLARGED  EDITION 

THIS  volume  presents  in  a  concise  manner  a  selection  of 
the  analytical  methods  employed  in  the  clinical  labora- 
tory  without  burdening  the   reader  with  unnecessary 
detail,  cumbersome  methods,  etc.,  which  are  extremely  difficult 
and  beyond  the  reach  of  the  practitioner. 

Such  new  methods  as  have  proven  reliable  have  been 
introduced.  Much  of  the  material  is  entirely  new,  and  many 
of  the  plates  and  cuts  have  been  prepared  'from  original  draw- 
ings and  photographs  by  the  author. 


FOURTEEN  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 


This  book  is  due  on  the  last  date  stamped  below,  or 

on  the  date  to  which  renewed. 
Renewed  books  are  subject  to  immediate  recall. 


-ait.  1  2  1956 


JUL  2  1  19t> 


LD  21-100m-2,'55 
(Bl39s22)476 


General  Library 

University  of  California 

Berkeley 


YC I  1 0737 


